Homograft implantation techniques in the aortic position: To preserve or replace the aortic root?

Background. One determinant of durability of the homograft in the aortic position is the implantation technique. This study uses meta- analytical techniques to evaluate the differences in early and long- term outcomes of patients undergoing aortic homograft implantation with either a root replacement or a root preserving technique. Methods. A systematic review of the literature ( 1965 2005) reporting results after homograft implantation in the aortic position with emphasis in the implantation technique was performed. Random and fixed- effects models were used. Cumulative and influential meta-analysis, graphic exploration, and sensitivity analysis were carried out to explain the heterogeneity between studies and to investigate potential publication bias. Results. Eleven studies were included. None of the studies was randomized. There was no significant difference in early mortality between root replacement and root preserving groups ( odds ratio = 2.57 with 95% confidence interval [ CI] 0.68 - 9.72 in random- effects model) and the root replacement group had a significantly lower rate of reoperation during long- term follow-up ( hazard ratio = 0.55 with 95% CI 0.38 - 0.80 in random- effects model). Subgroup analysis focusing on patients having the subcoronary technique for homograft implantation showed similar results. Significant heterogeneity between studies can be detected. No publication bias was found. Conclusions. There was no significant difference in early mortality between root replacement and root preserving groups. However, the root replacement technique group had a significantly lower rate of reoperation during long- term follow- up. Excluding outliers identified in a funnel plot reduced the heterogeneity and reached a similar conclusion.