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Balasubramanya A, Maes L, Rega F, Mazzi V, Morbiducci U, Famaey N, Degroote J, Segers P. Hemodynamics and wall shear metrics in a pulmonary autograft: Comparing a fluid-structure interaction and computational fluid dynamics approach. Comput Biol Med 2024; 176:108604. [PMID: 38761502 DOI: 10.1016/j.compbiomed.2024.108604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/02/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE In young patients, aortic valve disease is often treated by placement of a pulmonary autograft (PA) which adapts to its new environment through growth and remodeling. To better understand the hemodynamic forces acting on the highly distensible PA in the acute phase after surgery, we developed a fluid-structure interaction (FSI) framework and comprehensively compared hemodynamics and wall shear-stress (WSS) metrics with a computational fluid dynamic (CFD) simulation. METHODS The FSI framework couples a prestressed non-linear hyperelastic arterial tissue model with a fluid model using the in-house coupling code CoCoNuT. Geometry, material parameters and boundary conditions are based on in-vivo measurements. Hemodynamics, time-averaged WSS (TAWSS), oscillatory shear index (OSI) and topological shear variation index (TSVI) are evaluated qualitatively and quantitatively for 3 different sheeps. RESULTS Despite systolic-to-diastolic volumetric changes of the PA in the order of 20 %, the point-by-point correlation of TAWSS and OSI obtained through CFD and FSI remains high (r > 0.9, p < 0.01) for TAWSS and (r > 0.8, p < 0.01) for OSI). Instantaneous WSS divergence patterns qualitatively preserve similarities, but large deformations of the PA leads to a decrease of the correlation between FSI and CFD resolved TSVI (r < 0.7, p < 0.01). Moderate co-localization between FSI and CFD is observed for low thresholds of TAWSS and high thresholds of OSI and TSVI. CONCLUSION FSI might be warranted if we were to use the TSVI as a mechano-biological driver for growth and remodeling of PA due to varying intra-vascular flow structures and near wall hemodynamics because of the large expansion of the PA.
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Affiliation(s)
| | - Lauranne Maes
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Valentina Mazzi
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Umberto Morbiducci
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Nele Famaey
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Joris Degroote
- Department of Electromechanical Systems and Metal Engineering, Ghent University, Ghent, Belgium
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Vervenne T, Maes L, Van Hoof L, Rega F, Famaey N. Drivers of vascular growth and remodeling: A computational framework to promote benign adaptation in the Ross procedure. J Mech Behav Biomed Mater 2023; 148:106170. [PMID: 37852088 DOI: 10.1016/j.jmbbm.2023.106170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
In the sixties, Dr Donald Ross designed a surgical solution for young patients with aortic valve disease by using the patients' own pulmonary valve. The Ross procedure is the only aortic valve replacement technique that can restore long-term survival and preserve quality of life. The main failure mode of the Ross procedure is wall dilatation, potentially leading to valve regurgitation and leakage. Dilatation occurs due to the inability of the pulmonary autograft to adapt to the sudden increase in loading when exposing to aortic pressures. Previous experimental data has shown that a permanent external support wrapped around the artery can prevent the acute dilatation of the arterial wall. However, the textile support leads to stress-shielding phenomena due to the loss of mechanical wall compliance. We present a pragmatic and modular computational framework of arterial growth and remodeling predicting the long-term outcomes of cardiovascular tissue adaptation, with and without textile wrapping. The model integrates mean, systolic and diastolic pressures and assumes the resulting wall stresses to drive the biological remodeling rules. Rather than a single mean pressure or stress deviation from the homeostatic state, we demonstrate that only pulsatile stresses can predict available experimental results. Therefore, we suggest that a biodegradable external support could induce benign remodeling in the Ross procedure. Indeed, a biodegradable textile wrapped around the autograft fulfills the trade-off between prevention of acute dilatation on the one hand and recovery of arterial wall compliance on the other hand. After further validation, the computational framework can set the basis for the development of an actual biodegradable external support for the Ross procedure with optimized polymer mechanical properties and degradation behavior.
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Affiliation(s)
- Thibault Vervenne
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300, Leuven, 3001, Belgium.
| | - Lauranne Maes
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300, Leuven, 3001, Belgium
| | - Lucas Van Hoof
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49, Leuven, 3000, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49, Leuven, 3000, Belgium
| | - Nele Famaey
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300, Leuven, 3001, Belgium
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Maes L, Vervenne T, Van Hoof L, Jones EAV, Rega F, Famaey N. Computational modeling reveals inflammation-driven dilatation of the pulmonary autograft in aortic position. Biomech Model Mechanobiol 2023; 22:1555-1568. [PMID: 36764979 DOI: 10.1007/s10237-023-01694-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 01/17/2023] [Indexed: 02/12/2023]
Abstract
The pulmonary autograft in the Ross procedure, where the aortic valve is replaced by the patient's own pulmonary valve, is prone to failure due to dilatation. This is likely caused by tissue degradation and maladaptation, triggered by the higher experienced mechanical loads in aortic position. In order to further grasp the causes of dilatation, this study presents a model for tissue growth and remodeling of the pulmonary autograft, using the homogenized constrained mixture theory and equations for immuno- and mechano-mediated mass turnover. The model outcomes, compared to experimental data from an animal model of the pulmonary autograft in aortic position, show that inflammation likely plays an important role in the mass turnover of the tissue constituents and therefore in the autograft dilatation over time. We show a better match and prediction of long-term outcomes assuming immuno-mediated mass turnover, and show that there is no linear correlation between the stress-state of the material and mass production. Therefore, not only mechanobiological homeostatic adaption should be taken into account in the development of growth and remodeling models for arterial tissue in similar applications, but also inflammatory processes.
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Affiliation(s)
- Lauranne Maes
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300 box 2419, 3001, Leuven, Belgium.
| | - Thibault Vervenne
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300 box 2419, 3001, Leuven, Belgium
| | - Lucas Van Hoof
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49 box 276, 3000, Leuven, Belgium
| | - Elizabeth A V Jones
- Centre for Molecular and Vascular Biology, KU Leuven, UZ Herestraat 49 box 911, 3000, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49 box 276, 3000, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300 box 2419, 3001, Leuven, Belgium
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Mudigonda J, Onohara D, Amedi A, Suresh KS, Kono T, Corporan D, Padala M. In vivo efficacy of a polymer layered decellularized matrix composite as a cell honing cardiovascular tissue substitute. Mater Today Bio 2022; 17:100451. [DOI: 10.1016/j.mtbio.2022.100451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/22/2022] [Accepted: 10/03/2022] [Indexed: 11/25/2022] Open
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Cattapan C, Della Barbera M, Dedja A, Pavan P, Di Salvo G, Sabatino J, Avesani M, Padalino M, Guariento A, Basso C, Vida V. Mechanical and Structural Adaptation of the Pulmonary Root after Ross Operation in a Murine Model. J Clin Med 2022; 11:jcm11133742. [PMID: 35807025 PMCID: PMC9267924 DOI: 10.3390/jcm11133742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 01/25/2023] Open
Abstract
Background: The major limitation to the Ross operation is a progressive autograft dilation, possibly leading to reoperations. A murine model was created to evaluate pulmonary artery graft (PAG) adaptation to pressure overload. Methods: Lewis rats (n = 17) underwent heterotopic surgical implantation of a PAG, harvested from syngeneic animals (n = 17). A group of sham animals (n = 7) was used as a control. Seriated ultrasound studies of the PAG were performed. Animals were sacrificed at 1 week (n = 5) or 2 months (n = 15) and the PAG underwent mechanical and histopathological analyses. Results: Echography showed an initial increase in diameter (p < 0.001) and a decrease in peak systolic velocity (PSV). Subsequently, despite no change in diameter, an increase in PSV was observed (p < 0.01). After 1 week, the stiffness of the PAG and the aorta were similar, while at 2 months, the PAG appeared more rigid (p < 0.05). PAG’s histological analysis at 2 months revealed intimal hyperplasia development. The tunica media showed focal thinning of the elastic lamellae and normally distributed smooth muscle cells. Conclusions: We demonstrated a stiffening of the PAG wall after its implantation in systemic position; the development of intimal hyperplasia and the thinning of the elastic lamellae could be the possible underlying mechanism.
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Affiliation(s)
- Claudia Cattapan
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Mila Della Barbera
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (M.D.B.); (C.B.)
| | - Arben Dedja
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Piero Pavan
- Department of Industrial Engineering, University of Padua, 35131 Padua, Italy;
| | - Giovanni Di Salvo
- Pediatric Cardiology Unit, Department of Children and Woman’s Health, University of Padua, 35121 Padua, Italy; (G.D.S.); (J.S.); (M.A.)
| | - Jolanda Sabatino
- Pediatric Cardiology Unit, Department of Children and Woman’s Health, University of Padua, 35121 Padua, Italy; (G.D.S.); (J.S.); (M.A.)
| | - Martina Avesani
- Pediatric Cardiology Unit, Department of Children and Woman’s Health, University of Padua, 35121 Padua, Italy; (G.D.S.); (J.S.); (M.A.)
| | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Alvise Guariento
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (M.D.B.); (C.B.)
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
- Correspondence: ; Tel.: +39-049-821-2410
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DeCampli WM. Will we work out the Ross dilemma in 30 minutes?-Or 30 years? World J Pediatr Congenit Heart Surg 2022; 13:175-177. [PMID: 35238699 DOI: 10.1177/21501351221075839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- William M DeCampli
- Division of Cardiovascular Surgery, Arnold Palmer Hospital for Children, Orlando, FL, USA; Department of Clinical Sciences, University of Central Florida College of Medicine, Orlando, FL, USA
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Van Hoof L, Verbrugghe P, Jones EAV, Humphrey JD, Janssens S, Famaey N, Rega F. Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts. Front Cardiovasc Med 2022; 9:829120. [PMID: 35224059 PMCID: PMC8865563 DOI: 10.3389/fcvm.2022.829120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
The Ross, or pulmonary autograft, procedure presents a fascinating mechanobiological scenario. Due to the common embryological origin of the aortic and pulmonary root, the conotruncus, several authors have hypothesized that a pulmonary autograft has the innate potential to remodel into an aortic phenotype once exposed to systemic conditions. Most of our understanding of pulmonary autograft mechanobiology stems from the remodeling observed in the arterial wall, rather than the valve, simply because there have been many opportunities to study the walls of dilated autografts explanted at reoperation. While previous histological studies provided important clues on autograft adaptation, a comprehensive understanding of its determinants and underlying mechanisms is needed so that the Ross procedure can become a widely accepted aortic valve substitute in select patients. It is clear that protecting the autograft during the early adaptation phase is crucial to avoid initiating a sequence of pathological remodeling. External support in the freestanding Ross procedure should aim to prevent dilatation while simultaneously promoting remodeling, rather than preventing dilatation at the cost of vascular atrophy. To define the optimal mechanical properties and geometry for external support, the ideal conditions for autograft remodeling and the timeline of mechanical adaptation must be determined. We aimed to rigorously review pulmonary autograft remodeling after the Ross procedure. Starting from the developmental, microstructural and biomechanical differences between the pulmonary artery and aorta, we review autograft mechanobiology in relation to distinct clinical failure mechanisms while aiming to identify unmet clinical needs, gaps in current knowledge and areas for further research. By correlating clinical and experimental observations of autograft remodeling with established principles in cardiovascular mechanobiology, we aim to present an up-to-date overview of all factors involved in extracellular matrix remodeling, their interactions and potential underlying molecular mechanisms.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Jay D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Nappi F, Iervolino A, Avtaar Singh SS. The effectiveness and safety of pulmonary autograft as living tissue in Ross procedure: a systematic review. Transl Pediatr 2022; 11:280-297. [PMID: 35282027 PMCID: PMC8905099 DOI: 10.21037/tp-21-351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Reports on effectiveness and safety after the implant of pulmonary autograft (PA) living tissue in Ross procedure, to treat both congenital and acquired disease of the aortic valve and left ventricular outflow tract (LVOT), show variable durability results. We undertake a quantitative systematic review of evidence on outcome after the Ross procedure with the aim to improve insight into outcome and potential determinants. METHODS A systematic search of reports published from October 1979 to January 2021 was conducted (PubMed, Ovid Medline, Ovid Embase and Cochrane library) reporting outcomes after the Ross procedure in patients with diseased aortic valve with or without LVOT. Inclusion criteria were observational studies reporting on mortality and/or morbidity after autograft aortic valve or root replacement, completeness of follow-up >90%, and study size n≥30. Forty articles meeting the inclusion criteria were allocated to two categories: pediatric patient series and young adult patient series. Results were tabulated for a clearer presentation. RESULTS A total of 342 studies were evaluated of which forty studies were included in the final analysis as per the eligibility criteria. A total of 8,468 patients were included (7,796 in pediatric cohort and young adult series and 672 in pediatric series). Late mortality rates were remarkably low alongside similar age-matched mortality with the general population in young adults. There were differences in implantation techniques as regard the variability in stress and the somatic growth that recorded conflicting outcomes regarding the miniroot vs the subcoronary approach. DISCUSSION The adaptability of lung autograft to allow for both stress variability and somatic growth make it an ideal conduit for Ross's operation. The use of the miniroot technique over subcoronary implantation for better adaptability to withstand varying degrees of stress is perhaps more applicable to different patient subgroups.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
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Nakayama Y, Shinkawa T, Matsumura G, Hoki R, Kobayashi K, Yoshida H, Yamagishi M, Niinami H. Outcome of Pulmonary Autograft After the Ross Procedure. World J Pediatr Congenit Heart Surg 2021; 12:508-515. [PMID: 34278861 DOI: 10.1177/21501351211007802] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to assess autograft function after the Ross procedure and to review surgical outcomes associated with autograft reoperations. METHODS This is a retrospective study of patients undergoing the Ross procedure since 1993. Autograft function and autograft reoperation were studied. Autograft failure was defined as more than moderate autograft regurgitation or autograft dilatation to more than 50 mm diameter or z-score of more than +4 in children. One hospital death was excluded from analysis as were patients with unknown late autograft status. RESULTS Among 75 patients analyzed, preoperative diagnosis before the Ross procedure included aortic regurgitation in 26, aortic stenosis in 19, combined lesions in 28, and 2 mechanical valve malfunctions. Median age at the Ross procedure was 12.1 (0.4-43.6) years with 44 children less than 15 years old. Six patients had greater than mild autograft regurgitation at post-Ross hospital discharge. During median follow-up of 14.9 years, there were 23 autograft failures. Eighteen autograft reoperations were performed on 17 patients (13 children), including 12 aortic valve replacements, 5 aortic root replacements (including 1 valve-sparing root replacement), and 1 Konno procedure. Freedom from autograft failure and autograft reoperation at 20 years after the Ross procedure was 52.0% and 66.3%, respectively. Multivariate analysis identified greater than mild autograft regurgitation at hospital discharge from Ross procedure as a risk factor for autograft failure (P < .01). All patients who underwent autograft reoperation survived and had good health status at a median of 6.9 years after the reoperation. CONCLUSIONS The Ross procedure is effective in delaying prosthetic aortic valve replacement, although the time-related risk of autograft failure is a real consideration.
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Affiliation(s)
- Yuki Nakayama
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
| | - Takeshi Shinkawa
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
| | - Goki Matsumura
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
| | - Ryogo Hoki
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
| | - Kei Kobayashi
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
| | - Hisashi Yoshida
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
| | - Masaaki Yamagishi
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, The Heart Institute of Japan, 13131Tokyo Women's Medical University, Tokyo, Japan
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Yacoub MH, Tsang V, Sarathchandra P, Jensen H, Hughes S, Latif N. Long-term adaptive versus maladaptive remodelling of the pulmonary autograft after the Ross operation. Eur J Cardiothorac Surg 2021; 57:977-985. [PMID: 32129834 DOI: 10.1093/ejcts/ezaa019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Following the Ross operation, the pulmonary autograft undergoes structural changes (remodelling). We sought to determine the extent, nature and possible determinants of long-term remodelling in the different components of the pulmonary autograft. METHODS Ten pulmonary autografts and 12 normal control valves (6 pulmonary and 6 aortic) were examined by conventional histology, immunocytochemistry and electron microscopy. The structural changes were quantified by morphometry. RESULTS The leaflets from free-standing root replacement valves demonstrated thickening to levels comparable to the normal aortic leaflets, largely due to the addition of a thin layer of 'neointima' formed of radial elastic fibres, collagen bundles and glycoaminoglycans, on the ventricular aspect of the leaflets. The leaflets of valves from sub-coronary implantation demonstrated a significantly thicker fibroelastic layer on the ventricularis and calcium deposition in the fibrosa. The media of the explanted valves showed increased number of lamellar units to levels comparable to normal aortic roots. Electron microscopy of valves inserted as free-standing roots showed increased organization into continuous layers. However, intralamellar components showed varying degrees of 'disorganization' in comparison to those in the normal aortic media. In addition, there was a marked increase in the number of vasa vasorum with thickened arteriolar wall in the outer media and adventitia. CONCLUSIONS Following the Ross operation, in the very long term, all components of the autograft showed varying degrees of remodelling, which was judged to be largely adaptive. Defining the type, determinants and possible functional effects of remodelling could help in understanding and optimizing the results of the Ross operation.
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Affiliation(s)
- Magdi H Yacoub
- Department of Tissue Engineering, Imperial College London and Heart Science Centre, Harefield, Middlesex, UK
| | - Victor Tsang
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Padmini Sarathchandra
- Department of Tissue Engineering, Imperial College London and Heart Science Centre, Harefield, Middlesex, UK
| | - Hanna Jensen
- Department of Pathology, University College London, London, UK
| | - Sian Hughes
- Department of Pathology, University College London, London, UK
| | - Najma Latif
- Department of Tissue Engineering, Imperial College London and Heart Science Centre, Harefield, Middlesex, UK
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Generali T, Jansen K, Steedman R, De Rita F, Viganò G, McParlin D, Hermuzi A, Crossland D, O'Sullivan J, Coats L, Hasan A, Nassar MS. Contemporary Ross procedure outcomes: medium- to long-term results in 214 patients. Eur J Cardiothorac Surg 2021; 60:1112-1121. [PMID: 33969415 DOI: 10.1093/ejcts/ezab193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/18/2021] [Accepted: 02/22/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Our goal was to present 2 decades of our experience with the Ross procedure and its sequential modifications, adopted since 2010, to improve the reoperation rate. METHODS We performed a single-centre, retrospective review of database information and medical notes about the implantation technique: the freestanding root. We compared era 1 (1997-2009) and era 2 (2010-2019). RESULTS Between 1997 and 2019, a total of 214 Ross procedures were performed (71% men, median age 24 years) [interquartile range (IQR) 15-38]. Of these, 87% had various forms of congenital-dysplastic aortic valves. The median cross-clamping and bypass times were 173 (IQR 148-202) and 202 (IQR 182-244) min. The median postoperative stay was 6 days (2-77). Thirty-day mortality was 0.5%. The median follow-up time was 8.2 years (IQR 3.9-13.2). Survival at 10 and 20 years was 97% and 95%; freedom from greater than moderate aortic regurgitation or aortic valve intervention was 91% and 80%; and 93% of the patients were in New York Heart Association functional class I. Twenty (21%) patients operated on during era 1 and 6 (9%) during era 2 underwent autograft reoperations. The median follow-up time was 14.3 (IQR 11.5-17.4) and 4.8 (IQR 2.5-7) years. Freedom from autograft reoperation was 87% and 69% at 10 and 20 years, with no significant difference between eras. Freedom from homograft reoperation was 96% and 76% at 10 and 20 years. The presence of aortic regurgitation, infective endocarditis and era 1 were predictors of autograft reoperation. Male gender and era 1 were predictors of neoaortic root dilatation. CONCLUSIONS The contemporary modified Ross procedure continues to deliver excellent results and should remain part of the strategy to treat children and young adults requiring aortic valve replacement.
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Affiliation(s)
- T Generali
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - K Jansen
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Congenital Heart Disease Research Group, Population Health Science Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - R Steedman
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - F De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - G Viganò
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - D McParlin
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - A Hermuzi
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - D Crossland
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Congenital Heart Disease Research Group, Population Health Science Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - J O'Sullivan
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Congenital Heart Disease Research Group, Population Health Science Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - L Coats
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Congenital Heart Disease Research Group, Population Health Science Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - A Hasan
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - M S Nassar
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Congenital Heart Disease Research Group, Population Health Science Institute, Newcastle University, Newcastle Upon Tyne, UK
- Cardiothoracic Unit, Alexandria University, Alexandria, Egypt
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Vricella LA, El-Zein C, Hibino N, Rausa J, Roberson D, Ilbawi MN. Technical Modifications that Might Improve Long-Term Outcome of the Ross Procedure in Children. Ann Thorac Surg 2021; 112:1997-2004. [PMID: 33794157 DOI: 10.1016/j.athoracsur.2021.03.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Failure of the pulmonary autograft (PVA) following the Ross procedure (RP) has discouraged its widespread use and led to modifications or alternatives to the procedure. We sought to analyze whether certain technical modifications could improve results of the RP in children. METHODS Sixty-nine patients (median age 12 years, range 0.25 to 17.9) underwent the RP between 01/1996 and 12/2018. Concomitant Konno procedure was performed on 20/69 (29%). Prior interventions included balloon valvuloplasty in 30/69 (44%), and/or surgical valvuloplasty in 39/69 (57%). Technical modifications included utilizing the native aortic root for external annuloplasty, implanting the autograft using uniplanar horizontal sutures through the aortic wall, normalizing the sinotubular junction and wrapping the native root remnant around the PVA. RESULTS Operative mortality was 1/69 (1.5%), with no late death. No patient had neoaortic valvar stenosis and 7/68 (10%) had mild regurgitation on discharge echocardiogram. At latest follow-up (median 9.4 years, range 0.4 - 21.3) there was no significant change in the latest follow up Z scores of annulus, sinus or sinotubular junction diameters when compared to those at discharge. Three patients (4.4%) required late autograft replacement, two PVA repair, and two resection of pseudoaneurysm. Actuarial freedom from PVA replacement was 87% at 20 yrs. Freedom from right ventricular outflow tract catheter reintervention or reoperation was 83% and 80% respectively. CONCLUSIONS Technical modifications of the RP used in this cohort might successfully prolong the life of the PVA without compromising its growth, an important advantage in pediatric patients.
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Affiliation(s)
- Luca A Vricella
- The Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, IL; Department of Surgery, University of Chicago Medicine, Oak Lawn, IL.
| | - Chawki El-Zein
- The Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, IL
| | - Narutushi Hibino
- The Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, IL; Department of Surgery, University of Chicago Medicine, Oak Lawn, IL
| | - Jacqueline Rausa
- The Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, IL
| | - David Roberson
- The Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, IL
| | - Michel N Ilbawi
- The Heart Institute for Children, Advocate Children's Hospital, Oak Lawn, IL
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Schusterova I, Banovcinova A, Vachalcova M, Jakubova M, Artemiou P. Primary and secondary aortopathy associated with adult congenital heart disease - retrospective study. J Cardiothorac Surg 2020; 15:242. [PMID: 32912339 PMCID: PMC7488153 DOI: 10.1186/s13019-020-01283-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background Primary and secondary aortopathy are frequently encountered in patients with congenital heart disease. The aim of this study is to present our experience and the incidence of primary and secondary adult CHD-associated aortopathy. Methods The cohort is comprised of adult patients with congenital heart disease from the registry of the Eastern Slovakia Institute of Cardiovascular Diseases. Data from the last follow-up examinations are included in this study. In the primary and secondary aortopathy groups were 35 and 12 patients respectively. As a control group were selected 64 patients with non aortopathy associated congenital heart disease (atrial and ventricular septal defect). Results Patients with primary and secondary aortopathy had larger ascending aorta/aortic root diameters than the control group (36.28 (26–49) mm vs 30.25 (21–41) mm p = 0.000113, 33.82 27–49) mm vs 29.03 (19–38)mm p = 0.000366 and 42.1 (30–50) mm vs 30.25 (21–41) mm, p = 0.000106, 35.67 (27–48) mm vs 29.03 (19–38) mm, p = 0.000119 respectively). Moreover, patients with secondary aortopathy had statistically significant larger ascending aorta diameter compared to the patients with primary aortopathy (42.1 (30–50) mm vs 36.28 (26–49) mm p = 0.030). During the follow-up period, were performed only in 2 patients (one from each group) operations on the aortic root and the ascending aorta due to aortic root or ascending aorta dilatation. Conclusion More patients with secondary aortopathy had dilated ascending aorta/ aortic root, as well as larger aortic diameters compare to the patients with primary aortopathy. Routine follow-up of these patients with attention to aortic diameter is necessary.
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Affiliation(s)
- Ingrid Schusterova
- 1th Department of Cardiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Pavol Jozef Safarik University in Kosice, Kosice, Slovakia
| | - Alžbeta Banovcinova
- Department of Paediatrics and Adolescent Medicine, Faculty of Medicine, Pavol Jozef Safarik University in Kosice, Kosice, Slovakia
| | - Marianna Vachalcova
- 1th Department of Cardiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Pavol Jozef Safarik University in Kosice, Kosice, Slovakia
| | - Marta Jakubova
- 1th Department of Cardiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Pavol Jozef Safarik University in Kosice, Kosice, Slovakia
| | - Panagiotis Artemiou
- Medical Faculty of the Comenius University, National Institute of Cardiovascular Diseases, Clinic of Cardiac Surgery, Pod krasnou horkou 1, 83101, Bratislava, Slovakia.
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14
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Zilla P, Deutsch M, Bezuidenhout D, Davies NH, Pennel T. Progressive Reinvention or Destination Lost? Half a Century of Cardiovascular Tissue Engineering. Front Cardiovasc Med 2020; 7:159. [PMID: 33033720 PMCID: PMC7509093 DOI: 10.3389/fcvm.2020.00159] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
The concept of tissue engineering evolved long before the phrase was forged, driven by the thromboembolic complications associated with the early total artificial heart programs of the 1960s. Yet more than half a century of dedicated research has not fulfilled the promise of successful broad clinical implementation. A historical account outlines reasons for this scientific impasse. For one, there was a disconnect between distinct eras each characterized by different clinical needs and different advocates. Initiated by the pioneers of cardiac surgery attempting to create neointimas on total artificial hearts, tissue engineering became fashionable when vascular surgeons pursued the endothelialisation of vascular grafts in the late 1970s. A decade later, it were cardiac surgeons again who strived to improve the longevity of tissue heart valves, and lastly, cardiologists entered the fray pursuing myocardial regeneration. Each of these disciplines and eras started with immense enthusiasm but were only remotely aware of the preceding efforts. Over the decades, the growing complexity of cellular and molecular biology as well as polymer sciences have led to surgeons gradually being replaced by scientists as the champions of tissue engineering. Together with a widening chasm between clinical purpose, human pathobiology and laboratory-based solutions, clinical implementation increasingly faded away as the singular endpoint of all strategies. Moreover, a loss of insight into the healing of cardiovascular prostheses in humans resulted in the acceptance of misleading animal models compromising the translation from laboratory to clinical reality. This was most evident in vascular graft healing, where the two main impediments to the in-situ generation of functional tissue in humans remained unheeded–the trans-anastomotic outgrowth stoppage of endothelium and the build-up of an impenetrable surface thrombus. To overcome this dead-lock, research focus needs to shift from a biologically possible tissue regeneration response to one that is feasible at the intended site and in the intended host environment of patients. Equipped with an impressive toolbox of modern biomaterials and deep insight into cues for facilitated healing, reconnecting to the “user needs” of patients would bring one of the most exciting concepts of cardiovascular medicine closer to clinical reality.
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Affiliation(s)
- Peter Zilla
- Christiaan Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa.,Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
| | - Manfred Deutsch
- Karl Landsteiner Institute for Cardiovascular Surgical Research, Vienna, Austria
| | - Deon Bezuidenhout
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
| | - Neil H Davies
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
| | - Tim Pennel
- Christiaan Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
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15
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Mechano-biological adaptation of the pulmonary artery exposed to systemic conditions. Sci Rep 2020; 10:2724. [PMID: 32066803 PMCID: PMC7026065 DOI: 10.1038/s41598-020-59554-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/29/2020] [Indexed: 12/30/2022] Open
Abstract
Cardiac surgeries may expose pulmonary arterial tissue to systemic conditions, potentially resulting in failure of that tissue. Our goal was to quantitatively assess pulmonary artery adaptation due to changes in mechanical environment. In 17 sheep, we placed a pulmonary autograft in aortic position, with or without macroporous mesh reinforcement. It was exposed to systemic conditions for 6 months. All sheep underwent 3 ECG-gated MRI’s. Explanted tissue was subjected to mechanical and histological analysis. Results showed progressive dilatation of the unreinforced autograft, while reinforced autografts stabilized after two months. Some unreinforced pulmonary autograft samples displayed more aorta-like mechanical behavior with increased collagen deposition. The mechanical behavior of reinforced autografts was dominated by the mesh. The decrease in media thickness and loss of vascular smooth muscle cells was more pronounced in reinforced than in unreinforced autografts. In conclusion, altering the mechanical environment of a pulmonary artery causes changes in its mechano-biological properties.
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Konstantinov IE, Caldaroni F, Ivanov Y. Commentary: Prediction of pulmonary root dilatation after Ross operation—The power of protein shake? J Thorac Cardiovasc Surg 2020; 159:635-636. [DOI: 10.1016/j.jtcvs.2019.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/02/2019] [Indexed: 12/15/2022]
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17
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Chiarini A, Dal Prà I, Faggian G, Armato U, Luciani GB. Maladaptive remodeling of pulmonary artery root autografts after Ross procedure: A proteomic study. J Thorac Cardiovasc Surg 2020; 159:621-632.e3. [DOI: 10.1016/j.jtcvs.2019.07.083] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/26/2019] [Accepted: 07/02/2019] [Indexed: 12/15/2022]
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18
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Von Stumm M, Petersen J, Westermann D, Reichenspurner H, Girdauskas E. Treatment strategies for mixed aortic valve disease in nonelderly patients. Expert Rev Cardiovasc Ther 2019; 17:873-882. [DOI: 10.1080/14779072.2019.1702520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Von Stumm
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J. Petersen
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - D. Westermann
- Department of Cardiology, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Chauvette V, Chamberland MÈ, El-Hamamsy I. A review of pulmonary autograft external support in the Ross procedure. Expert Rev Med Devices 2019; 16:981-988. [PMID: 31663385 DOI: 10.1080/17434440.2019.1685380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Although the Ross procedure offers several advantages over standard prosthetic AVR, its use remains limited. The risk of pulmonary autograft dilatation requiring reintervention remains one of the main concerns. Consequently, multiple techniques have been developed in attempt to mitigate this complication.Areas covered: This article reviews the incidence of pulmonary autograft dilatation, its risk factors and pathophysiology. The techniques of external pulmonary autograft support are discussed along with their respective advantages and limitations. Finally, future areas of research and developments are examined.Expert opinion: The risk of autograft dilatation is mainly prevalent in patients with aortic regurgitation and a dilated aortic annulus. In these selected patients, an external support may prevent dilatation of the autograft. However, any permanent support potentially restricts autograft root motion, mitigating some of the advantages associated with the Ross procedure. A bioresorbable matrix that could support the root during its initial adaptative phase could alleviate this problem. In our opinion, aggressive blood pressure control during the first postoperative year along with annular and sino-tubular junction support in selected patients provides optimal stability of autograft root dimensions while preserving root dynamics. Serial imaging and clinical follow-up are necessary to define the role of these various strategies.
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Affiliation(s)
- Vincent Chauvette
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
| | | | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
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20
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Sievers HH. Reply: Does adaptation prevent calcification? J Thorac Cardiovasc Surg 2019; 159:e169-e170. [PMID: 31630839 DOI: 10.1016/j.jtcvs.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 08/30/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany
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21
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Tissue Level Mechanical Properties and Extracellular Matrix Investigation of the Bovine Jugular Venous Valve Tissue. Bioengineering (Basel) 2019; 6:bioengineering6020045. [PMID: 31091689 PMCID: PMC6630446 DOI: 10.3390/bioengineering6020045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 12/19/2022] Open
Abstract
Jugular venous valve incompetence has no long-term remedy and symptoms of transient global amnesia and/or intracranial hypertension continue to discomfort patients. During this study, we interrogate the synergy of the collagen and elastin microstructure that compose the bi-layer extracellular matrix (ECM) of the jugular venous valve. In this study, we investigate the jugular venous valve and relate it to tissue-level mechanical properties, fibril orientation and fibril composition to improve fundamental knowledge of the jugular venous valves toward the development of bioprosthetic venous valve replacements. Steps include: (1) multi loading biaxial mechanical tests; (2) isolation of the elastin microstructure; (3) imaging of the elastin microstructure; and (4) imaging of the collagen microstructure, including an experimental analysis of crimp. Results from this study show that, during a 3:1 loading ratio (circumferential direction: 900 mN and radial direction: 300 mN), elastin may have the ability to contribute to the circumferential mechanical properties at low strains, for example, shifting the inflection point toward lower strains in comparison to other loading ratios. After isolating the elastin microstructure, light microscopy revealed that the overall elastin orients in the radial direction while forming a crosslinked mesh. Collagen fibers were found undulated, aligning in parallel with neighboring fibers and orienting in the circumferential direction with an interquartile range of -10.38° to 7.58° from the circumferential axis (n = 20). Collagen crimp wavelength and amplitude was found to be 38.46 ± 8.06 µm and 4.51 ± 1.65 µm, respectively (n = 87). Analyzing collagen crimp shows that crimp permits about 12% true strain circumferentially, while straightening of the overall fibers accounts for more. To the best of the authors' knowledge, this is the first study of the jugular venous valve linking the composition and orientation of the ECM to its mechanical properties and this study will aid in forming a structure-based constitutive model.
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22
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Ando Y, Ochiai Y, Tokunaga S, Hisahara M, Baba H, Miyagi C, Takigawa T. Size and Stiffness of the Pulmonary Autograft after the Ross Procedure in Children. Pediatr Cardiol 2019; 40:776-783. [PMID: 30734094 DOI: 10.1007/s00246-019-02064-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/29/2019] [Indexed: 11/24/2022]
Abstract
Progressive dilatation of the pulmonary autograft is one of the greatest concerns after the Ross procedure. Increased stress in the arterial wall may cause changes in the elastic properties of the pulmonary autograft, and thus lead to pathological dilatation. The present study aimed to investigate the changes in the autograft diameter and stiffness during follow-up after the Ross procedure. A total of ten patients underwent the Ross procedure at our institution between 2003 and 2011. Echocardiography was used to measure the diameters of the pulmonary autograft at the level of the annulus, sinus of Valsalva, and sinotubular junction. The stiffness index was calculated from the angiographic data, and compared with that of 16 age-matched control children. The diameters of the pulmonary autograft increased throughout the follow-up period, particularly at the level of the sinus of Valsalva and at the sinotubular junction. The aortic root was stiffer in Ross patients compared with control children (7.9 ± 1.8 vs. 3.9 ± 0.7 immediately postoperatively, p < 0.01; 10.1 ± 2.8 vs. 4.2 ± 1.4 at 5 years postoperatively, p < 0.01). Although no significant relationship was found between the stiffness index and the autograft diameter, the stiffness index tended to increase over time. Dilatation of the pulmonary autograft was accompanied by progressive change in aortic stiffness. Longer follow-up is warranted to clarify the impact of this change in aortic stiffness on autograft failure.
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Affiliation(s)
- Yusuke Ando
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan.
| | - Yoshie Ochiai
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Shigehiko Tokunaga
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Manabu Hisahara
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Hironori Baba
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Chihiro Miyagi
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Tomoya Takigawa
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
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23
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Biomechanical evaluation of a personalized external aortic root support applied in the Ross procedure. J Mech Behav Biomed Mater 2017; 78:164-174. [PMID: 29156355 DOI: 10.1016/j.jmbbm.2017.11.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 11/07/2017] [Accepted: 11/09/2017] [Indexed: 02/07/2023]
Abstract
A commonly heard concern in the Ross procedure, where a diseased aortic valve is replaced by the patient's own pulmonary valve, is the possibility of pulmonary autograft dilatation. We performed a biomechanical investigation of the use of a personalized external aortic root support or exostent as a possibility for supporting the autograft. In ten sheep a short length of pulmonary artery was interposed in the descending aorta, serving as a simplified version of the Ross procedure. In seven of these cases, the autograft was supported by an external mesh or so-called exostent. Three sheep served as control, of which one was excluded from the mechanical testing. The sheep were sacrificed six months after the procedure. Samples of the relevant tissues were obtained for subsequent mechanical testing: normal aorta, normal pulmonary artery, aorta with exostent, pulmonary artery with exostent, and pulmonary artery in aortic position for six months. After mechanical testing, the material parameters of the Gasser-Ogden-Holzapfel model were determined for the different tissue types. Stress-strain curves of the different tissue types show significantly different mechanical behavior. At baseline, stress-strain curves of the pulmonary artery are lower than aortic stress-strain curves, but at the strain levels at which the collagen fibers are recruited, the pulmonary artery behaves stiffer than the aorta. After being in aortic position for six months, the pulmonary artery tends towards aorta-like behavior, indicating that growth and remodeling processes have taken place. When adding an exostent around the pulmonary autograft, the mechanical behavior of the composite artery (exostent + artery) differs from the artery alone, the non-linearity being more evident in the former.
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24
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Wissing TB, Bonito V, Bouten CVC, Smits AIPM. Biomaterial-driven in situ cardiovascular tissue engineering-a multi-disciplinary perspective. NPJ Regen Med 2017; 2:18. [PMID: 29302354 PMCID: PMC5677971 DOI: 10.1038/s41536-017-0023-2] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 05/11/2017] [Accepted: 05/19/2017] [Indexed: 12/13/2022] Open
Abstract
There is a persistent and growing clinical need for readily-available substitutes for heart valves and small-diameter blood vessels. In situ tissue engineering is emerging as a disruptive new technology, providing ready-to-use biodegradable, cell-free constructs which are designed to induce regeneration upon implantation, directly in the functional site. The induced regenerative process hinges around the host response to the implanted biomaterial and the interplay between immune cells, stem/progenitor cell and tissue cells in the microenvironment provided by the scaffold in the hemodynamic environment. Recapitulating the complex tissue microstructure and function of cardiovascular tissues is a highly challenging target. Therein the scaffold plays an instructive role, providing the microenvironment that attracts and harbors host cells, modulating the inflammatory response, and acting as a temporal roadmap for new tissue to be formed. Moreover, the biomechanical loads imposed by the hemodynamic environment play a pivotal role. Here, we provide a multidisciplinary view on in situ cardiovascular tissue engineering using synthetic scaffolds; starting from the state-of-the art, the principles of the biomaterial-driven host response and wound healing and the cellular players involved, toward the impact of the biomechanical, physical, and biochemical microenvironmental cues that are given by the scaffold design. To conclude, we pinpoint and further address the main current challenges for in situ cardiovascular regeneration, namely the achievement of tissue homeostasis, the development of predictive models for long-term performances of the implanted grafts, and the necessity for stratification for successful clinical translation.
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Affiliation(s)
- Tamar B Wissing
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Valentina Bonito
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Carlijn V C Bouten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Anthal I P M Smits
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
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25
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Mookhoek A, Krishnan K, Chitsaz S, Kuang H, Ge L, Schoof PH, Bogers AJ, Takkenberg JJ, Tseng EE. Biomechanics of Failed Pulmonary Autografts Compared to Native Aortic Roots. Ann Thorac Surg 2017; 103:1482-1488. [DOI: 10.1016/j.athoracsur.2016.08.061] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 11/29/2022]
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26
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Abstract
The Ross operation provides several advantages compared to other valve substitutes to manage aortic valve disease, such as growth potential, excellent hemodynamics, freedom from oral anticoagulation and hemolysis, and better durability. However, progressive dilatation of the pulmonary autografts after Ross operation reflects the inadequate remodeling of the native pulmonary root in the systemic circulation, which results in impaired adaptability to systemic pressure and risk of reoperation after the first decade. A recently published article showed that remodeling increased wall thickness and decreased stiffness in the failed specimens after Ross operation, and the increased compliance might play a key role in determining the progressive long-term autograft root dilatation. Late dilatation can be counteracted by an external barrier which prevents failure. Therefore, an inclusion cylinder technique with a native aorta or a synthetic external support, such as Dacron, might stabilize the autograft root and improve long-term outcomes. In this article, we offer a prospective about the importance of biomechanical features in future developments of the Ross operation. Pre-clinical and clinical evaluations of the biomechanical properties of these reinforced pulmonary autografts might shed new light on the current debate about the long-term fate of the pulmonary autograft after Ross procedure.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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27
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Mookhoek A, Krishnan K, Chitsaz S, Kuang H, Ge L, Schoof PH, Bogers AJJC, Takkenberg JJM, Tseng EE. Biomechanics of Failed Pulmonary Autografts Compared With Normal Pulmonary Roots. Ann Thorac Surg 2016; 102:1996-2002. [PMID: 27457832 DOI: 10.1016/j.athoracsur.2016.05.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Progressive dilatation of pulmonary autografts after the Ross operation may reflect inadequate remodeling of the native pulmonary root to adapt to systemic circulation. Understanding the biomechanics of autograft root dilatation may aid designing strategies to prevent dilatation. We have previously characterized normal human pulmonary root material properties; however, the mechanical properties of failed autografts are unknown. In this study, failed autograft roots explanted during reoperation were acquired, and their material properties were determined. METHODS Failed pulmonary autograft specimens were obtained from patients undergoing reoperation after the Ross operation. Fresh human native pulmonary roots were obtained from the transplant donor network as controls. Biaxial stretch testing was performed to determine tissue mechanical properties. Tissue stiffness was determined at patient-specific physiologic stresses at pulmonary pressures. RESULTS Nonlinear stress-strain response was present in both failed autografts and normal pulmonary roots. Explanted pulmonary autografts were less stiff than were their native pulmonary root counterparts at 8 mm Hg (134 ± 42 vs 175 ± 49 kPa, respectively) (p = 0.086) and 25 mm Hg (369 ± 105 vs 919 ± 353 kPa, respectively) (p = 0.006). Autograft wall stiffness at both 8 and 25 mm Hg was not correlated with age at the Ross procedure (p = 0.898 and p = 0.813, respectively) or with time in the systemic circulation (p = 0.609 and p = 0.702, respectively). CONCLUSIONS Failed pulmonary autografts retained nonlinear response to mechanical loading typical of healthy human arterial tissue. Remodeling increased wall thickness but decreased wall stiffness in failed autografts. Increased compliance may explain progressive autograft root dilatation in autograft failures.
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Affiliation(s)
- Aart Mookhoek
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kapil Krishnan
- Department of Surgery, University of California San Francisco Medical Center and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Sam Chitsaz
- Division of Cardiology, Department of Medicine, University of Texas at Houston, Houston, Texas
| | - Heide Kuang
- Department of Surgery, University of California San Francisco Medical Center and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Liang Ge
- Department of Surgery, University of California San Francisco Medical Center and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Paul H Schoof
- Department of Pediatric Cardiothoracic Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elaine E Tseng
- Department of Surgery, University of California San Francisco Medical Center and San Francisco Veterans Affairs Medical Center, San Francisco, California.
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Abstract
In patients born with congenital heart disease, dilatation of the aorta is a frequent feature at presentation and during follow-up after surgical intervention. This review provides an overview of the pathologies associated with aortopathy, and discusses the current knowledge on pathophysiology, evolution, and treatment guidelines of the aortic disease associated with congenital heart defects.
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Affiliation(s)
- Katrien Francois
- Department of Cardiac Surgery, University Hospital Gent, De Pintelaan, Gent, Belgium
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Mol A, Smits AIPM, Bouten CVC, Baaijens FPT. Tissue engineering of heart valves: advances and current challenges. Expert Rev Med Devices 2014; 6:259-75. [DOI: 10.1586/erd.09.12] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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30
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Soares ALF, van Geemen D, van den Bogaerdt AJ, Oomens CWJ, Bouten CVC, Baaijens FPT. Mechanics of the pulmonary valve in the aortic position. J Mech Behav Biomed Mater 2013; 29:557-67. [PMID: 24035437 DOI: 10.1016/j.jmbbm.2013.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 07/02/2013] [Accepted: 07/04/2013] [Indexed: 01/09/2023]
Abstract
Mathematical models can provide valuable information to assess and evaluate the mechanical behavior and remodeling of native tissue. A relevant example when studying collagen remodeling is the Ross procedure because it involves placing the pulmonary autograft in the more demanding aortic valve mechanical environment. The objective of this study was therefore to assess and evaluate the mechanical differences between the aortic valve and pulmonary valve and the remodeling that may occur in the pulmonary valve when placed in the aortic position. The results from biaxial tensile tests of pairs of human aortic and pulmonary valves were compared and used to determine the parameters of a structurally based constitutive model. Finite element analyzes were then performed to simulate the mechanical response of both valves to the aortic diastolic load. Additionally, remodeling laws were applied to assess the remodeling of the pulmonary valve leaflet to the new environment. The pulmonary valve showed to be more extensible and less anisotropic than the aortic valve. When exposed to aortic pressure, the pulmonary leaflet appeared to remodel by increasing its thickness and reorganizing its collagen fibers, rotating them toward the circumferential direction.
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Affiliation(s)
- A L F Soares
- Eindhoven University of Technology, Eindhoven, The Netherlands.
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31
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Abstract
BACKGROUND It is unclear how autografts grow and dilate after the Ross operation in children. We analysed autograft growth and dilatation in children who underwent the Ross operation and examined the relationship of these factors to autograft failure. METHODS From our institutional database, we retrospectively identified 33 children who underwent the Ross operation without aortic root reinforcement (mean age 9.9 years) and had normal body measurements and echocardiographic data throughout follow-up. RESULTS Autograft insufficiency developed in 10 patients 5.1 years after the Ross operation. The average Z score at the development of autograft insufficiency was -0.1 (range from -2.0 to 6.1). The proportions of patients who remained free of autograft insufficiency at 5 and 10 years were 87.2% and 55.7%, respectively. A consistent trend in the time course of Z score was not found in any age group studied. CONCLUSIONS Autograft growth and dilation after the Ross operation varied widely among patients, and the incidence of autograft insufficiency was independent of annulus size.
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32
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Goldstone AB, Woo YJ. Pulmonary autograft leaflet repair and valve sparing root replacement to correct late failure of the ross procedure. J Card Surg 2013; 28:496-9. [PMID: 23782261 DOI: 10.1111/jocs.12150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Delayed pulmonary autograft failure is the principal limitation of the Ross procedure. Although reoperation typically includes replacement of the neoaortic valve, strategies for autograft valve preservation are becoming increasingly employed. However, leaflet prolapse and asymmetry are deterrents to valve preservation in this technically complex surgical population. The present report illustrates the technical considerations in performing an autograft valve preserving aortic root replacement with direct leaflet repair for the surgical correction of aortic insufficiency and root aneurysm late after a successful Ross procedure.
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Affiliation(s)
- Andrew B Goldstone
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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33
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Alsoufi B, Ahmed D, Manlhiot C, Al-Halees Z, McCrindle BW, Fadel BM. Fate of the remaining neo-aortic root after autograft valve replacement with a stented prosthesis for the failing ross procedure. Ann Thorac Surg 2013; 96:59-65; discussion 565. [PMID: 23743060 DOI: 10.1016/j.athoracsur.2013.04.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/10/2013] [Accepted: 04/15/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aortic root replacement (ARR) is advocated for irreparable autograft failure after the Ross procedure to avoid late aneurysm formation. However, redo ARR is complex and associated with bleeding and coronary injury risks. We examine results of autograft valve replacement (AuVR) with stented prostheses (SP) without ARR with special focus on the fate of the remaining root and need for reintervention. METHODS Between 1994 and 2011, 50 of 510 Ross patients underwent AuVR with SP. Serial postoperative echocardiograms (n = 342) were analyzed and regression models adjusted for repeated measures were used to model longitudinal change of the remaining root and ascending aorta dimensions after AuVR. RESULTS Fifty patients, median age 21 years (range 11 to 50 years) underwent AuVR with SP: mechanical (n = 38) or tissue (n = 12). Thirty patients (60%) had concomitant procedures; most commonly mitral valve surgery (n = 20) or conduit change (n = 12). There were no operative deaths and 10-year survival was 95%. Freedom from prosthesis, root, and all-cause reoperations was 97%, 98%, and 90% at 10 years, respectively. Serial echocardiography data showed that there was little but, nevertheless, progressive increase of the remaining root (EST: +0.0190 [0.0041] cm/year, p < 0.001) and ascending aorta diameters (EST: +0.0191 [0.0037] cm/year, p < 0.001). While there was small steady non-statistically significant increase in mean prosthesis gradient (estimate [EST]: +0.16 [0.09] mm Hg/year, p = 0.08); ejection fraction remained stable with time (EST: -0.12 [0.14] %/year, p = 0.41). CONCLUSIONS Our results indicate that AuVR with SP without ARR for failing autografts is justified as it is associated with low mortality and reoperation risk. Preemptive complex ARR should be reserved for those with significant root dilatation at time of AuVR. Although root reinterventions are rare, patients should be followed for progressive root dilatation. Faster growth is seen in those who fail with regurgitation and dilated annulus.
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Affiliation(s)
- Bahaaldin Alsoufi
- Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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34
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VanderLaan PA, Padera RF, Schoen FJ. Practical Approach to the Evaluation of Prosthetic Mechanical and Tissue Replacement Heart Valves. Surg Pathol Clin 2012; 5:353-69. [PMID: 26838108 DOI: 10.1016/j.path.2012.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Mechanical and bioprosthetic substitute heart valves have dramatically improved life expectancy and quality of life in patients with valvular heart disease. Complications of substitute heart valves are a relatively infrequent occurrence, often due to thrombosis, infection, or structural/mechanical failure. It is important to accurately identify and systematically evaluate prosthetic heart valves when encountered as surgical pathology specimens or in the autopsy setting.
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Affiliation(s)
- Paul A VanderLaan
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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35
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Brinkman WT, Herbert MA, Prince SL, Ryan C, Ryan WH. Redo Autograft Operations After the Ross Procedure. Ann Thorac Surg 2012; 93:1477-81; discussion 1481-22. [DOI: 10.1016/j.athoracsur.2012.01.100] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 01/25/2012] [Accepted: 01/31/2012] [Indexed: 11/25/2022]
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36
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Ross Root Dilation in Adult Patients: Is Preoperative Aortic Insufficiency Associated With Increased Late Autograft Reoperation? Ann Thorac Surg 2011; 92:74-81; discussion 81. [DOI: 10.1016/j.athoracsur.2011.02.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/02/2011] [Accepted: 02/07/2011] [Indexed: 11/23/2022]
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37
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Totally biological composite aortic stentless valved conduit for aortic root replacement: 10-year experience. J Cardiothorac Surg 2011; 6:86. [PMID: 21699696 PMCID: PMC3145569 DOI: 10.1186/1749-8090-6-86] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 06/23/2011] [Indexed: 11/14/2022] Open
Abstract
Objectives To retrospectively analyze the clinical outcome of a totally biological composite stentless aortic valved conduit (No-React® BioConduit) implanted using the Bentall procedure over ten years in a single centre. Methods Between 27/10/99 and 19/01/08, the No-React® BioConduit composite graft was implanted in 67 patients. Data on these patients were collected from the in-hospital database, from patient notes and from questionnaires. A cohort of patients had 2D-echocardiogram with an average of 4.3 ± 0.45 years post-operatively to evaluate valve function, calcification, and the diameter of the conduit. Results Implantation in 67 patients represented a follow-up of 371.3 patient-year. Males were 60% of the operated population, with a mean age of 67.9 ± 1.3 years (range 34.1-83.8 years), 21 of them below the age of 65. After a mean follow-up of 7.1 ± 0.3 years (range of 2.2-10.5 years), more than 50% of the survivors were in NYHA I/II and more than 60% of the survivors were angina-free (CCS 0). The overall 10-year survival following replacement of the aortic valve and root was 51%. During this period, 88% of patients were free from valved-conduit related complications leading to mortality. Post-operative echocardiography studies showed no evidence of stenosis, dilatation, calcification or thrombosis. Importantly, during the 10-year follow-up period no failures of the valved conduit were reported, suggesting that the tissue of the conduit does not structurally change (histology of one explant showed normal cusp and conduit). Conclusions The No-React® BioConduit composite stentless aortic valved conduit provides excellent long-term clinical results for aortic root replacement with few prosthesis-related complications in the first post-operative decade.
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Malvindi PG, van Putte BP, Leone A, Heijmen RH, Schepens MAAM, Morshuis WJ. Aortic reoperation after freestanding homograft and pulmonary autograft root replacement. Ann Thorac Surg 2011; 91:1135-40. [PMID: 21353201 DOI: 10.1016/j.athoracsur.2011.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 01/03/2011] [Accepted: 01/04/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Human allografts and pulmonary autografts offer many advantages as an aortic valve and root substitute. The progressive degeneration of the aortic allograft and the pulmonary autograft has been seen as an important disadvantage, and the need for a reoperation has been perceived as challenging and risky for the patients. METHODS Between March 1992 and October 2009, 53 consecutive patients (mean age 50 ± 13 years; 38 male), who had a previous aortic root replacement, underwent redo surgery for failure of the aortic homograft (n = 42) or the pulmonary autograft (n = 11). The median follow-up (available for 47 of 51 patients) was 44 months. RESULTS Structural valve deterioration was the main indication for reoperation on the homograft (86%), with an earlier presentation in patients who received homografts from donors more than 55 years old. Failure of the pulmonary autograft occurred primarily because of severe aortic regurgitation predominantly due to dilation of the autograft (n = 5) and autograft valve prolapse (n = 5). The total in-hospital mortality was 3.8% (n = 2). No deaths occurred among patients who previously underwent a Ross procedure. The course was complicated in 25 cases (48%). The cumulative 1-year, 5-year, and 8-year survival rates were 92%, 90%, and 77%, respectively. No late deaths were encountered after reoperation on the pulmonary autograft (maximum follow-up 218 months). Freedom from reoperation (excluding early in-hospital operation) for recurrent aortic valve or root pathology was 97% at 8 years. CONCLUSIONS Reoperation after freestanding homograft and pulmonary autograft root replacement can be accomplished safely. The total postoperative morbidity rate is still high.
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Affiliation(s)
- Pietro G Malvindi
- Department of Cardiac Surgery, IRCCS Istituto Clinico Humanitas, Rozzano, Italy.
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39
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Mookhoek A, de Heer E, Bogers AJJC, Takkenberg JJM, Schoof PH. Pulmonary autograft valve explants show typical degeneration. J Thorac Cardiovasc Surg 2010; 139:1416-9. [PMID: 20363479 DOI: 10.1016/j.jtcvs.2010.01.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Revised: 12/28/2009] [Accepted: 01/10/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to evaluate the microscopic characteristics of pulmonary autograft valve explants. METHODS Cell density and thickness of the autograft valve ventricularis were determined and compared with those of normal aortic and pulmonary valves (n = 11). Cellular phenotype and extracellular matrix involvement were assessed with immunohistochemistry. Collagen 3-dimensional architecture was studied by means of confocal microscopy. RESULTS The autograft valve exhibited characteristic thickening of the ventricularis compared with the normal aortic and pulmonary valves (137 vs 77 [P = .058] vs 37 mum [P = .002], respectively). Its cell number was increased compared with those of the normal aortic and pulmonary valves (396 vs 230 [P = .02] vs 303 [P = .083], respectively). Myofibroblasts and stressed endothelial cells, both of which were present in pulmonary autografts, were absent in control valves. The exclusive presence of matrix metalloproteinase 1 was an additional sign of extracellular matrix turnover. Apoptosis, elastinolysis, cell proliferation, and senescence were not expressed. Dense fibrosis of the autograft ventricularis with relatively well-aligned collagen fibers was observed with confocal microscopy. CONCLUSIONS Fibrous hyperplasia of the ventricularis and cellular and extracellular matrix characteristics of active remodeling were a consistent finding in pulmonary autograft valve explants. The observations suggest a primary valve-related cause to be involved in pulmonary autograft valve failure.
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Affiliation(s)
- Aart Mookhoek
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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40
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Luciani GB, Viscardi F, Pilati M, Prioli AM, Faggian G, Mazzucco A. The Ross–Yacoub procedure for aneurysmal autograft roots: A strategy to preserve autologous pulmonary valves. J Thorac Cardiovasc Surg 2010; 139:536-42. [DOI: 10.1016/j.jtcvs.2009.08.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 06/18/2009] [Accepted: 08/10/2009] [Indexed: 12/01/2022]
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41
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Midterm Results of Ross Aortic Valve Replacement: A Single-Institution Experience. Ann Thorac Surg 2009; 88:601-7; discussion 607-8. [PMID: 19632420 DOI: 10.1016/j.athoracsur.2009.05.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 05/01/2009] [Accepted: 05/05/2009] [Indexed: 11/22/2022]
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42
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Rubbens MP, Mol A, van Marion MH, Hanemaaijer R, Bank RA, Baaijens FP, Bouten CV. Straining Mode–Dependent Collagen Remodeling in Engineered Cardiovascular Tissue. Tissue Eng Part A 2009; 15:841-9. [DOI: 10.1089/ten.tea.2008.0185] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mirjam P. Rubbens
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Anita Mol
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Mieke H. van Marion
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | | | - Ruud A. Bank
- Department of Tissue Repair, TNO Quality of Life, Leiden, The Netherlands
| | - Frank P.T. Baaijens
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Carlijn V.C. Bouten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
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Takkenberg JJ, Klieverik LM, Schoof PH, van Suylen RJ, van Herwerden LA, Zondervan PE, Roos-Hesselink JW, Eijkemans MJ, Yacoub MH, Bogers AJ. The Ross Procedure. Circulation 2009; 119:222-8. [DOI: 10.1161/circulationaha.107.726349] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Reports on outcome after the Ross procedure are limited by small study size and show variable durability results. A systematic review of evidence on outcome after the Ross procedure may improve insight into outcome and potential determinants.
Methods and Results—
A systematic review of reports published from January 2000 to January 2008 on outcome after the Ross procedure was undertaken. Thirty-nine articles meeting the inclusion criteria were allocated to 3 categories: (1) consecutive series, (2) adult patient series, and (3) pediatric patient series. With the use of an inverse variance approach, pooled morbidity and mortality rates were obtained. Pooled early mortality for consecutive, adult, and pediatric patients series was 3.0% (95% confidence interval [CI], 1.8 to 4.9), 3.2% (95% CI, 1.5 to 6.6), and 4.2% (95% CI, 1.4 to 11.5). Autograft deterioration rates were 1.15% (95% CI, 1.06 to 2.06), 0.78% (95% CI, 0.43 to 1.40), and 1.38%/patient-year (95% CI, 0.68 to 2.80), respectively, and for right ventricular outflow tract conduit were 0.91% (95% CI, 0.56 to 1.47), 0.55% (95% CI, 0.26 to 1.17), and 1.60%/patient-year (95% CI, 0.84 to 3.05), respectively. For studies with mean patient age >18 years versus mean patient age ≤18 years, pooled autograft and right ventricular outflow tract deterioration rates were 1.14% (95% CI, 0.83 to 1.57) versus 1.69% (95% CI, 1.02 to 2.79) and 0.65% (95% CI, 0.41 to 1.02) versus 1.66%/patient-year (95% CI, 0.98 to 2.82), respectively.
Conclusions—
The Ross procedure provides satisfactory results for both children and young adults. Durability limitations become apparent by the end of the first postoperative decade, in particular in younger patients.
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Affiliation(s)
- Johanna J.M. Takkenberg
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Loes M.A. Klieverik
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Paul H. Schoof
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Robert-Jan van Suylen
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Lex A. van Herwerden
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Pieter E. Zondervan
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Jolien W. Roos-Hesselink
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Marinus J.C. Eijkemans
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Magdi H. Yacoub
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Ad J.J.C. Bogers
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
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de Kerchove L, Rubay J, Pasquet A, Poncelet A, Ovaert C, Pirotte M, Buche M, D'Hoore W, Noirhomme P, El Khoury G. Ross Operation in the Adult: Long-Term Outcomes After Root Replacement and Inclusion Techniques. Ann Thorac Surg 2009; 87:95-102. [DOI: 10.1016/j.athoracsur.2008.09.031] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 09/10/2008] [Accepted: 09/11/2008] [Indexed: 11/26/2022]
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Klieverik LMA, Takkenberg JJM, Bekkers JA, Roos-Hesselink JW, Witsenburg M, Bogers AJJC. The Ross operation: a Trojan horse?†. Eur Heart J 2007; 28:1993-2000. [PMID: 17303586 DOI: 10.1093/eurheartj/ehl550] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS The Ross operation is the operation of choice for children who require aortic valve replacement (AVR) and may also provide a good option in selected adult patients. Although the autograft does not require anticoagulation and has a superior haemodynamic profile, concern regarding autograft and allograft longevity has risen. In this light, we report the 13-year results of our prospective autograft cohort study. METHODS AND RESULTS Between 1988 and 2005, 146 consecutive patients underwent AVR with a pulmonary autograft at Erasmus Medical Center Rotterdam. Mean age was 22 years (SD 13; range 4 months-52 years), 66% were male. Hospital mortality was 2.7% (N = 4); during follow-up four more patients died. Thirteen-year survival was 94 +/- 2%. Over time, 22 patients required autograft reoperation for progressive neo-aortic root dilatation. In addition, eight patients required allograft reoperation. Freedom from autograft reoperation at 13 years was 69 +/- 7%. Freedom from allograft reoperation for structural failure at 13 years was 87 +/- 5%. Risk factors for autograft reoperation were previous AVR and adult patient age. CONCLUSION Although survival of the Rotterdam autograft cohort is excellent, over time a worrisome increase in reoperation rate is observed. Given the progressive autograft dilatation, careful follow-up of these patients is warranted in the second decade after operation.
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Affiliation(s)
- Loes M A Klieverik
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Bd 571, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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