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(Circulation. 2000;102:III-15.)
© 2000 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Aortic Root Characteristics of Human Pulmonary Autografts

Gerald S. Carr-White, MRCP; A. Afoke, PhD; E. J. Birks, MRCP; S. Hughes, MBBS; A. O’Halloran; Sally Glennen, RGN; Sue Edwards, BSc; M. Eastwood, PhD; Magdi H. Yacoub, FRS

From the Department of Academic Surgery (G.S.C.-W., E.J.B., S.H., A.O., S.G., S.E., M.H.Y.), National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Sydney Street, London, UK; and Centre for Tissue Engineering Research (A.A., M.E.), University of Westminster, London, UK. Correspondence to Prof Sir Magdi Yacoub, Professor of Cardiothoracic Surgery, National Heart and Lung Institute, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.

Background—After pulmonary autograft replacement of the aortic valve and root, the pulmonary artery (PA) wall is subjected to higher pressures. Concern exists that this may lead to structural and functional changes in the implanted autograft and subsequent aortic root dilatation and neoaortic regurgitation. We therefore assessed root dimensions and neoaortic regurgitation, morphological structure, and mechanical behavior in patients who underwent the Ross operation.

Methods and Results—Seventy-four patients who were randomized to undergo aortic valve replacement with an aortic homograft or a pulmonary autograft were followed up echocardiographically for up to 4 years and had their aortic root dimensions measured at the level of the annulus, sinuses, and sinotubular junction. In a separate series of 18 patients who underwent pulmonary autograft surgery and 8 normal organ donors, samples from the PA and aorta were analyzed for medial wall thickness, distribution of the staining of collagen and elastin, and elastin fragmentation. Finally, stress-strain curves were obtained from samples of the PA and aorta from 9 patients who underwent pulmonary autograft surgery and from 1 patient in whom a 4-month-old autograft was explanted. No patient in either group had aortic dilatation at any level of >20% or more than mild aortic regurgitation at up to 4 years of follow-up. The aortic media was thicker in both autografts and normal donors (P<0.01), and there was a trend for the PA media to be thicker in the autograft group. Elastic fiber in all aortas showed little or no variation, whereas in the PA, there was considerable variation in fragmentation. Patients with higher preoperative PA pressures tended to have lower fragmentation scores (² P<0.01). The lower stiffness modulus, higher stiffness modulus, and maximum tensile strength of the aorta was 34% to 38% higher than that of the PA (P<0.01); however, the 4-month-old autograft appeared to show adaptation in mechanical behavior.

Conclusions—In our series of patients, there was no significant progressive dilatation of the aortic root. We demonstrated differences in the anatomic structure and mechanical behavior of the PA in vitro and highlighted histological and mechanical modes of adaptation.

Key Words: aorta • valves • arteries • grafting