Objective: Efforts towards more physiological aortic valve replacements are still ongoing. The Ross procedure or aortic valve remodelling and reimplantation techniques (David/Yacoub operations, DY) are alternatives in suitable patients. The aim of the study was to compare transvalvular hemodynamics including extra transvalvular stroke work of autografts and DY with that of bioprostheses (Magna ease, ME) and native aortic valves during exercise and recovery. Similarly, analyses were performed for pulmonary homografts and native valves.

Methods: Stress-echocardiography was performed up to 75 watt in 45 patients with autografts, 17 patients with DY, 19 patients with ME and 26 healthy volunteers as well as 66 patients with homografts and corresponding 31 controls. At every exercise level and during recovery, valvular flow, mean transvalvular pressure gradient, resistance and extra transvalvular stroke work were determined.

Results: All hemodynamic parameters including transvalvular resistance and extra stroke work were significantly elevated in ME compared to autograft, DY, and controls during exertion, and recovery. The latter three showed no significant differences. Homografts, however, demonstrated impaired hemodynamics with increased extra stroke work compared to native controls

Conclusions: DY and autograft showed excellent flow hemodynamics comparable to native aortic valves with no detectable extra stroke work for the left ventricle. However, ME and homograft in the pulmonary valve position developed increased valve resistance compared to native controls, which placed additional transvalvular stroke work on the ventricles. From an energetic point of view, DY is therefore the best surgical choice for patients with aortic regurgitation, if anatomy is suitable.