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J Thorac Cardiovasc Surg 2009;137:334-341
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Propensity analysis of survival after subcoronary or root replacement techniques for homograft aortic valve replacement

Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, United Kingdom

Received for publication December 1, 2007; revisions received September 5, 2008; accepted for publication October 9, 2008.

^_* Address for reprints: Ayyaz Ali, MRCS, Department of Cardiothoracic Surgery, Royal Brompton Hospital, Sydney St, London SW3 3NP, United Kingdom. (Email: Ayyaz75{at}gmail.com).

Objective: Homograft aortic valve replacement is associated with excellent clinical and hemodynamic outcomes. Valves are implanted predominantly by using 2 techniques: the freehand subcoronary technique or as an aortic root replacement. Our aim was to identify any difference in survival, durability, and clinical performance.

Methods: Demographic, operative, and clinical data were obtained retrospectively through case-note review. All operations were performed by a single surgeon. Propensity score–adjusted analysis was used by developing a nonparsimonious logistic regression model for implantation with subcoronary versus root replacement. Actuarial survival and freedom from valve-related events were compared with Kaplan–Meier curves and multivariable proportional hazard Cox regression.

Results: Between January 1, 1991, and January 1, 2001, 215 patients underwent aortic valve replacement with a homograft. The subcoronary technique was used in 131 (61%) patients. Eighty-four (39%) patients underwent free-standing aortic root replacement. After propensity risk adjustment, the subcoronary implantation technique was associated with a decreased risk of 30-day death (adjusted odds ratio, 0.18; 95% confidence interval, 0.06–0.34; P = .03). Technique of insertion was not an independent predictor of overall mortality during follow-up after adjustment (propensity adjusted hazard ratio, 0.35; 95% confidence interval, 0.09–1.41; P = .18). There were no significant differences in 1- and 5-year actuarial survival, freedom from structural valve disease, endocarditis, or reoperation.

Conclusions: Both the subcoronary and root replacement techniques for homograft aortic valve replacement are associated with excellent midterm survival and clinical performance. Root replacement was associated with an increased risk of perioperative death after adjustment for covariates by using propensity analysis.