Long-Term Outcomes After Autograft Versus Homograft Aortic Root Replacement ln Adults With Aortic Valve Disease - Autograft Versus Homograft AVR


The goal of the trial was to evaluate aortic valve replacement (AVR) by autograft (Ross procedure) compared with homograft technique among patients with severe aortic valve disease.


Autograft AVR would be more effective in improving long-term survival.

Study Design

  • Randomized
  • Parallel

Patient Populations:

  • Patients 18-69 years of age with severe aortic valve disease

Number of enrollees: 228

Duration of follow-up: mean 10.2 years

Age: mean 38 years

Percentage female: 15%

New York Heart Association class: I 31%, II 45%, III 19%, and IV 5%


  • Marfan’s syndrome
  • Rheumatoid arthritis
  • Reiter’s syndrome

Primary Endpoints:

  • Survival 10 years after surgery

Secondary Endpoints:

  • Reoperation for aortic or pulmonary valve disease

Drug/Procedures Used:

Patients undergoing AVR were randomized to aortic autograft (n = 116) versus aortic homograft (n = 112).

The autograft technique harvests the patient’s own pulmonary valve, which is then sewn into the aortic position, and a pulmonary homograft is sewn into the pulmonary position. Homograft technique prepares valves from human cadavers.

Principal Findings:

Overall, 228 patients were randomized. In the autograft group, the mean age was 38 years, 15% were women, mean body surface area was 1.9 m2, 17% were current smokers, and 17% had active or treated endocarditis. Indication for surgery: aortic stenosis in 28%, aortic regurgitation in 45%, mixed aortic stenosis/regurgitation in 27%, and thoracic aortic aneurysm in 2%. Forty-two percent of patients had previous intervention: homograft in 22%, mechanical or tissue prosthesis in 12%, aortic valve repair in 11%, or coarctation repair in 8%.

There was one perioperative death in the autograft group versus three in the homograft group (p = 0.62). Bypass time was 163 minutes versus 117 minutes (p < 0.0001), re-exploration for bleeding was 12% versus 4% (p = 0.041), sternal wound infection occurred in 4% versus 1% (p = 0.37), and median hospital stay was 9 days versus 9 days (p = 0.45), respectively.

The primary outcome, survival at 10 years, was 97% in the autograft group versus 83% in the homograft group (p = 0.006). The proportion surviving in the autograft group was similar to an age- and sex-matched United Kingdom population. Freedom from aortic valve reoperation at 13 years was 99% versus 51% (p < 0.0003), and freedom from aortic or pulmonary valve reoperation was 94% versus 51% (p < 0.0001), respectively.


Among patients with severe aortic valve disease, the autograft AVR (Ross procedure) was associated with improved long-term survival compared with the homograft AVR. Survival in the autograft group was similar to an age- and sex-matched United Kingdom cohort. Procedurally, patients in the autograft group experienced longer bypass time and more reoperation for bleeding; however, the duration of the hospital stay was the same in both groups. Autograft AVR was also associated with improved freedom from reoperation on the aortic valve or aortic/pulmonary valves. Future studies are needed that compare the autograft to mechanical or xenogenic bioprosthetic valves.


El-Hamamsy I, Eryigit Z, Stevens LM, et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 2010;Aug 3:[Epub ahead of print].

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Vascular Medicine, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease, CHD and Pediatrics and Quality Improvement

Keywords: Heart Valve Prosthesis, Aortic Aneurysm, Thoracic, Follow-Up Studies, Heart Defects, Congenital, Allografts, Wound Infection, Pulmonary Valve, Length of Stay, Body Surface Area, Reoperation, Endocarditis, Cadaver, Autografts

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