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Ungerleider RM, Walsh M, Ootaki Y. A modification of the pulmonary autograft procedure to prevent late autograft dilatation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:38-42. [PMID: 24725715 DOI: 10.1053/j.pcsu.2014.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Although the pulmonary autograft procedure for aortic valve replacement is a commonly utilized option for children, its use is diminishing in adult-aged patients. One commonly cited concern is the tendency for the pulmonary autograft to dilate in the aortic position. This article reviews a technique we have used in 36 patients since October, 2004 that stabilizes the autograft so that it cannot dilate. There have been no operative or late deaths and the autograft has continued to function in 34 patients. Two patients have undergone autograft replacement because of early failure, which we believe was likely related to technical considerations in our early technique (first reported in the 2005 STCVS Pediatric Cardiac Surgery Annual). The technical modifications described in this article have produced a more reliable and reproducible technique and have not resulted in any autograft failures in our experience. One patient with Marfan's syndrome and a bicuspid aortic valve is symptom- and dilation-free 8 years post op, with no autograft or pulmonary homograft insufficiency, normal activity and a stable aortic root by serial echocardiography. Our results suggest that this technique might be applicable for selected adult patients in whom autograft growth is not necessary and for whom the risk of autograft dilatation would provide a reason to avoid a pulmonary autograft procedure.
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Affiliation(s)
| | - Michael Walsh
- Brenner Children's Hospital, Wake Forest University, Winston Salem, NC
| | - Yoshio Ootaki
- Brenner Children's Hospital, Wake Forest University, Winston Salem, NC
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Stelzer P. The Ross procedure: state of the art 2011. Semin Thorac Cardiovasc Surg 2012; 23:115-23. [PMID: 22041040 DOI: 10.1053/j.semtcvs.2011.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2011] [Indexed: 11/11/2022]
Abstract
The purpose of this paper is to review the current literature and practice of the Ross concept of using the autologous pulmonary valve to replace a diseased aortic valve. The potential advantages and disadvantages of these operations will be evaluated in the context of alternative options and relative risks. The different surgical techniques of subcoronary and full root methods will be discussed and important technical aspects reviewed. Long-term outcomes will be described to the extent these are available, including recent publications describing a survival advantage for the Ross. Brief discussions will be presented regarding hemodynamics, child-bearing, endocarditis, and the use of the Ross in pediatric patients as well as biological adaptability of the living pulmonary autograft.
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Affiliation(s)
- Paul Stelzer
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York 10029, USA.
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Yuan SM, Shinfeld A, Tager S, Raanani E. Onset of neoaortic root dilation 18 years after an arterial switch operation. J Cardiovasc Med (Hagerstown) 2008; 9:298-300. [PMID: 18301152 DOI: 10.2459/jcm.0b013e32815aa5e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It has been claimed that neoaortic root dilatation or enlargement with aortic regurgitation is progressive until 11 years after an arterial switch operation. We report a case of neoaortic root dilatation onset occurring 18 years after operation and discuss the pathological features and the possible acting mechanisms.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiac and Thoracic Surgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Pasquali SK, Cohen MS, Shera D, Wernovsky G, Spray TL, Marino BS. The Relationship Between Neo-Aortic Root Dilation, Insufficiency, and Reintervention Following the Ross Procedure in Infants, Children, and Young Adults. J Am Coll Cardiol 2007; 49:1806-12. [PMID: 17466232 DOI: 10.1016/j.jacc.2007.01.071] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Revised: 12/20/2006] [Accepted: 01/09/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The purpose of this study was to describe the relationship between neo-aortic root size, neo-aortic insufficiency (AI), and reintervention at mid-term follow-up. BACKGROUND Data on neo-aortic valve function and growth after the Ross procedure in children are limited. METHODS A total of 74 of 119 Ross patients from January 1995 to December 2003 had > or =2 follow-up echocardiograms at our institution and were included. Neo-aortic dimensions were converted to z-scores and modeled over time. Kaplan-Meier analysis was used to assess freedom from neo-aortic outcomes, and predictors were identified through multivariate analysis. RESULTS Median age at Ross was 9 years (range 3 days to 34 years). Over 4.7 years (range 3 months to 9.3 years) follow-up, there was disproportionate enlargement of the neo-aortic root (z-score increase of 0.75/year [p < 0.0001]). Neo-AI progressed > or =1 grade in 36% of patients and > or =2 grades in 15%. Nine patients (12%) had neo-aortic reintervention at 2.0 years (range 1.1 to 9.5 years) after the Ross procedure owing to severe neo-AI (n = 7), neo-aortic root dilation (n = 1), and neo-aortic pseudoaneurysm (n = 1). At 6 years after the Ross procedure, freedom from neo-aortic reintervention was 88%. Freedom from neo-aortic root z-score >4 was only 3% and from moderate or greater neo-AI was 60%. Longer follow-up time was associated with neo-aortic root dilation (p < 0.0001). Prior ventricular septal defect (VSD) repair predicted neo-AI (p = 0.02) and reintervention (p = 0.03). Prior aortic valve replacement (p = 0.002) also predicted neo-AI. Neo-aortic root dilation was not associated with neo-AI or reintervention. CONCLUSIONS At mid-term follow-up after the Ross procedure, neo-aortic root size increases significantly out of proportion to somatic growth, and neo-AI is progressive. Prior VSD repair and aortic valve replacement were associated with neo-AI and reintervention.
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Affiliation(s)
- Sara K Pasquali
- Division of Cardiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Pasquali SK, Shera D, Wernovsky G, Cohen MS, Tabbutt S, Nicolson S, Spray TL, Marino BS. Midterm outcomes and predictors of reintervention after the Ross procedure in infants, children, and young adults. J Thorac Cardiovasc Surg 2007; 133:893-9. [PMID: 17382622 DOI: 10.1016/j.jtcvs.2006.12.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 10/03/2006] [Accepted: 12/18/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study assessed the type, time course, and risk factors for right and left ventricular outflow tract reinterventions after the Ross procedure in a population of infants, children, and young adults. METHODS Patients who underwent the Ross procedure between January 1995 and June 2004 were included (n = 121 consecutive patients). Kaplan-Meier and hazard analyses of right and left ventricular outflow tract reinterventions were performed, and predictors of reintervention were identified through multivariate analysis. RESULTS The median age at the Ross procedure was 8.2 years (4 days to 34 years); 20% were aged less than 1 year. Half of the patients had isolated aortic valve disease; the other half had complex left-sided heart disease. Early mortality (<30 days) was 2.5% (n = 3). There were 2 late deaths (1.7%). Follow-up (median 6.5 years [2.5 months to 10.4 years]) was available for 96% of survivors (n = 111). Right ventricular outflow tract reintervention (n = 22 in 15 patients) was performed 2.0 years (2.0 weeks to 9.8 years) after the Ross procedure because of stenosis in 19 of 22 cases. Freedom from right ventricular outflow tract reintervention at 8 years was 81%. Smaller homograft size was the strongest predictor (P < .001) of right ventricular outflow tract reintervention. Left ventricular outflow tract reintervention (n = 15 in 15 patients) was performed 2.8 years (1.0 months to 11.6 years) after the Ross procedure because of severe neoaortic insufficiency in 10 of 15 patients. Freedom from left ventricular outflow tract reintervention at 8 years was 83%. Native pulmonary valve abnormalities (P < .01), original diagnosis of aortic insufficiency (P < .01), prior aortic valve replacement (P = .01), and prior ventricular septal defect repair (P = .04) predicted left ventricular outflow tract reintervention. CONCLUSIONS At midterm follow-up after the Ross procedure, interim mortality is rare. Neoaortic insufficiency and right ventricle to pulmonary artery conduit obstruction are common postoperative sequelae, requiring reintervention in one quarter of patients.
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Affiliation(s)
- Sara K Pasquali
- Division of Cardiology in the Departments of Pediatrics, Surgery, and Anesthesia/Critical Care Medicine at The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pa 19104, USA
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Abstract
For patients requiring intervention because of progressive disease of the aortic valve, the perfect palliation will provide a valve that produces normal dynamics of flow, will not require anti-coagulation, will grow with the patient, and have long term durability. Current surgical interventions include aortic valvoplasty, or replacement with either a mechanical or tissue prosthesis. Options for tissue valves include insertion of a pulmonary autograft in the Ross procedure, a cadaveric homograft, or porcine or bovine xenograft valves. The optimal option is still debated.
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Affiliation(s)
- Bradley S Marino
- Divisione of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA.
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Villavicencio RE, Humes RA, Epstein ML, Walters HL, Hakimi M, Thomas RL, Tantengco MVT. Abrupt aortic root dilation after the Ross procedure--is this a progressive phenomenon? J Card Surg 2003; 18:384-9. [PMID: 12974922 DOI: 10.1046/j.1540-8191.2003.02045.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study provides evidence of aortic root dilation in children, adolescents, and young adults who have undergone the Ross procedure. Several mechanisms are described.
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Affiliation(s)
- Rafael E Villavicencio
- Department of Pediatrics, Division of Cardiology, Wayne State University School of Medicine, Detroit, MI, USA
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Cohen MS, Marino BS, McElhinney DB, Robbers-Visser D, van der Woerd W, Gaynor JW, Spray TL, Wernovsky G. Neo-aortic root dilation and valve regurgitation up to 21 years after staged reconstruction for hypoplastic left heart syndrome. J Am Coll Cardiol 2003; 42:533-40. [PMID: 12906985 DOI: 10.1016/s0735-1097(03)00715-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We sought to assess the prevalence and progression of neo-aortic root dilation and valvar regurgitation after staged reconstruction for hypoplastic left heart syndrome (HLHS). BACKGROUND In HLHS, the pulmonary valve functions as the neo-aortic valve. Neo-aortic valve dysfunction has been observed after arterial switch operation and the Ross procedure. METHODS Patients with HLHS born before January 1995 who had the Fontan operation and had serial echocardiograms were included. Echocardiograms were reviewed preoperatively, after each surgical reconstruction, and at most recent follow-up for neo-aortic root size and severity of neo-aortic regurgitation (AR). Potential risk factors for neo-aortic valve dysfunction were assessed. RESULTS Fifty-three patients met inclusion criteria. Bidirectional superior cavopulmonary anastomosis as an interim procedure was performed in 39 patients (74%). Median duration of follow-up was 9.2 (range 5.1 to 21) years. During follow-up, the neo-aortic root progressively dilated out of proportion to body size over time, with 52 patients (98%) having a Z-score >2 at most recent follow-up. Neo-AR was present in 61% of patients at most recent follow-up, with progression over time in 26 patients (49%). However, neo-AR was more than mild in only three patients. Significantly larger neo-aortic root Z-scores were observed in patients with any degree of neo-AR at most recent follow-up. No other anatomic or clinical variables correlated with severity of neo-AR or root dilation. CONCLUSIONS After staged reconstruction for HLHS, neo-aortic root dilation and neo-AR progress over time. Early volume unloading does not have a beneficial impact on dilation of the neo-aortic root. These findings raise concerns about neo-aortic valve function into adulthood.
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Affiliation(s)
- Meryl S Cohen
- Department of Pediatrics, University of Pennsylvania School of Medicine, Cardiac Center at Children's Hospital of Philadelphia, 19104, USA.
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Ishizaka T, Devaney EJ, Ramsburgh SR, Suzuki T, Ohye RG, Bove EL. Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure. Ann Thorac Surg 2003; 75:1518-22. [PMID: 12735572 DOI: 10.1016/s0003-4975(02)04904-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Aortic insufficiency secondary to progressive dilatation of the pulmonary autograft is being recognized with increasing frequency after the Ross procedure. We reviewed our experience with valve-sparing aortic root replacement concomitant with aortic annuloplasty to assess the effectiveness of this approach. METHODS Four patients, aged 8 to 27 years, presented with moderate to severe aortic insufficiency associated with progressive root dilatation from 1 to 8 years after a Ross procedure. All patients had 0 to 1+ aortic insufficiency early after the Ross procedure, with a mean maximal sinus diameter of 37 mm (range 30 to 45 mm). At reoperation the maximum diameter of the root ranged from 45 to 55 mm (mean 50 +/- 4 mm). A valve-sparing aortic root replacement with annular reduction was performed. The annulus was decreased from a mean of 27 mm to 23 mm. For the root replacement, 1 patient underwent a standard root remodeling procedure; in the others, a separate piece of scalloped Dacron (C.R. Bard, Haverhill, PA) graft material was used for each sinus to facilitate optimal exposure. RESULTS All 4 patients are in New York Heart Association functional class I at a mean follow-up of 6 months. The most recent echocardiography demonstrated 0 to 1+ aortic insufficiency with good left ventricular function. Histology of the excised pulmonary autograft walls demonstrated severe elastin fragmentation. CONCLUSIONS Aortic root remodeling with annular reduction is an effective treatment for aortic root dilatation and aortic insufficiency after the Ross operation. This procedure allows correction of aortic insufficiency and avoids the need for a prosthetic valve and anticoagulation.
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Affiliation(s)
- Toru Ishizaka
- Division of Pediatric Cardiovascular Surgery, Section of Cardiac Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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Bacha EA, Satou GM, Moran AM, Zurakowski D, Marx GR, Keane JF, Jonas RA. Valve-sparing operation for balloon-induced aortic regurgitation in congenital aortic stenosis. J Thorac Cardiovasc Surg 2001; 122:162-8. [PMID: 11436050 DOI: 10.1067/mtc.2001.114639] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Aortic regurgitation after balloon dilation of congenital aortic stenosis may be treated with valve repair as an alternative to replacement. METHODS Charts and echocardiograms of all patients undergoing aortic valve operations after balloon dilation of congenital aortic stenosis at our institution between January 1988 and December 1999 were reviewed. RESULTS Twenty-one patients underwent valvuloplasty for predominant aortic regurgitation 9 months to 15 years (mean, 6.1 years) after balloon dilation. The mean +/- SD age at the time of the operation was 11 +/- 7 years. Aortic regurgitation was caused by a combination of commissural avulsion (10), cusp dehiscence with retraction (9), cusp tear (5), central incompetence (2), perforated cusp (1), or cusp adhesion to the aortic wall (1). Repair techniques included commissural reconstruction with a pericardial patch (8), pericardial patch cusp augmentation (6), primary suture repair (6), raphae release and debridement (4), commissurotomy (4), commissural resuspension with sutures (3), and cusp release (1). There were no deaths. At a mean follow-up of 30.1 months (range, 9 months-8 years), all patients were asymptomatic, and the grade of aortic regurgitation had been significantly reduced (P <.001). Left ventricular end-diastolic dimension z scores and proximal regurgitant jet/aortic anulus diameter ratios were significantly reduced (P <.001) and remained so over time. Freedom from reoperation for late failure was 100%, and overall freedom from reintervention was 80% at 3 years. CONCLUSION Aortic valve repair for balloon-induced aortic regurgitation is reproducible and durable at medium-term follow-up.
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Affiliation(s)
- E A Bacha
- Department of Cardiovascular Surgery, Children's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND The optimal hemodynamic performance and potential growth of the pulmonary autograft has led to expanded indications for the Ross procedure. We reviewed our institutional experience to assess midterm results with the Ross operation. METHODS In a 7-year period (1992 to 1999), 111 patients with a median age of 15.7 years (range 2 days to 67 years), underwent the Ross procedure. Ninety-five patients had isolated aortic valve disease and 16 pediatric patients had a more complex left ventricular outflow tract obstruction. RESULTS There were 3 early (2.7%) and 3 late deaths over a median follow-up of 3.6 years (range 6 months to 7.6 years). Actuarial survival at 5 years was 94%+/-2%. In pediatric patients, the pulmonary autograft annulus enlarged from 14.7+/-6.2 mm to 22+/-6.3 mm. This growth followed the expected increase in pulmonary valve diameter based on body surface area. Eight reoperations were necessary for autograft insufficiency at a median interval of 14 months (range 2 days to 31 months). Freedom from replacement of the pulmonary autograft was 91%+/-3% at 5 years. Three patients developed important obstruction of the pulmonary homograft requiring reoperation at a median of 29 months (range 9 to 31 months). CONCLUSIONS The Ross procedure can be performed with good midterm results. In pediatric patients, autograft growth has been appropriate. The potential for development of important autograft insufficiency suggests close follow-up through the intermediate and late term.
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Affiliation(s)
- R Pessotto
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles 90027, USA
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