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(Circulation. 2009;120:S269-S275.)
© 2009 American Heart Association, Inc.

Surgery for Aortic Disease

Rate of Progression and Functional Significance of Aortic Root Calcification After Homograft Versus Freestyle Aortic Root Replacement

Ismail El-Hamamsy, MD; Mohamed Zaki, MRCP; Louis M. Stevens, MD; Lucy A. Clark, PhD; Michael Rubens, MD; Giovanni Melina, MD; Magdi H. Yacoub, FRS

From Department of Cardiac Surgery (I.E.-H., L.A.C., G.M., M.H.Y.) and Radiology (M.Z., M.R.), Harefield and Royal Brompton NHS Trust, National Heart and Lung Institute, Imperial College London, London, UK; Harvard School of Public Health (L.M.S.), Harvard University, Boston, Mass.

Correspondence to Sir Magdi H. Yacoub, FRS, Harefield Heart Science Center, Harefield Hospital, Hill End Road, Harefield, Middlesex, United Kingdom. E-mail m.yacoub{at}imperial.ac.uk

Background— Calcification is an important limitation after aortic root replacement. The aims were to compare the long-term degree and rate of calcification of homografts versus Medtronic freestyle aortic roots to determine the functional consequences and predictive factors.

Methods and Results— One hundred sixty-six patients were prospectively randomized to undergo homograft versus freestyle total aortic root replacement. Of those, 98 patients underwent a total of 248 electron beam computed tomography studies at 0.5, 1, 1.5, 2, 3, and 8 years. All patients underwent yearly clinical and echocardiographic follow-up. Calcium scores were measured using Agatston scoring. Mixed effects models demonstrate significantly higher calcium scores in homograft roots than freestyle at 1.5 years (P=0.02), 2 years (P=0.02), and 3 years (P=0.01), with a trend at 1 year (P=0.06) and 8 years (P=0.1). Homograft calcification occurs significantly faster than in freestyle prostheses between 6 months and 3 years after surgery (P=0.02). Calcification occurs at a similar rate thereafter up to 8 years (P=0.3). At 8 years, freedom from aortic valve dysfunction was lower in homografts than freestyle roots (P=0.06). Freedom from reoperation was 93±4% in the homograft group versus 100±0% in the freestyle group at 8 years (P=0.01). On multivariate analysis, redo surgery (P<0.001), smoking (P<0.01), atrial fibrillation (P=0.001), family history of coronary artery disease (P<0.01), and a degenerative etiology (P=0.02) were predictive of higher calcium scores.

Conclusion— Homograft roots exhibit significantly higher calcium scores than freestyle roots because of faster early calcification.

Key Words: calcium • homografts • imaging • valves • xenografts