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Galzerano D, Kholaif N, Al Amro B, Al Admawi M, Eltayeb A, Alshammari A, Di Salvo G, Al-Halees ZY. The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement. J Clin Med 2024; 13:630. [PMID: 38276135 PMCID: PMC10816914 DOI: 10.3390/jcm13020630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 01/27/2024] Open
Abstract
The Ross procedure is gaining recognition as a significant option for aortic valve replacement (AVR), and is particularly beneficial in specific patient groups. Although categorized as a class IIb recommendation in the 2020 American College of Cardiology (ACC)/American Heart Association (AHA), and the European Society of Cardiology (ESC) management guidelines on valvular heart disease, recent studies bolster its credibility. Research, including a propensity-matched study, underlines the Ross procedure's association with enhanced long-term survival and reduced adverse valve-related events compared to other AVR types. This positions the Ross procedure as a primary option for AVR in young and middle-aged adults within specialized centers, and potentially the only choice for children and infants requiring AVR. This review meticulously examines the Ross procedure, covering historical perspectives, surgical techniques, imaging, and outcomes, including hemodynamic performance and quality of life, especially focusing on pediatric and young adult patients. It explores contemporary techniques and innovations like minimally invasive approaches and tissue engineering, underscoring ongoing research and future directions. A summarization of comparative studies and meta-analyses reiterates the Ross procedure's superior long-term outcomes, valve durability, and preservation of the left ventricular function, accentuating the crucial role of patient selection and risk stratification, and pinpointing areas for future research.
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Affiliation(s)
- Domenico Galzerano
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Naji Kholaif
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Bandar Al Amro
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Mohammed Al Admawi
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Abdalla Eltayeb
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Amal Alshammari
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Giovanni Di Salvo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Medical School, University of Padua, 35122 Padua, Italy;
| | - Zohair Y. Al-Halees
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
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Outcomes after the Ross procedure with pulmonary autograft reinforcement by reimplantation. JTCVS Tech 2022; 17:121-128. [PMID: 36820346 PMCID: PMC9938391 DOI: 10.1016/j.xjtc.2022.11.016] [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: 06/14/2022] [Revised: 10/31/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022] Open
Abstract
Background Pulmonary autograft reinforcement to prevent dilatation and subsequent neo-aortic valve regurgitation has been reported; however, data on long-term function of the neo-aortic valve after this modified Ross procedure are lacking. Our objective here was to assess long-term outcomes of the modified Ross procedure with autograft reinforcement using the reimplantation technique. Patients The outcomes of 61 consecutive patients managed using the Dacron-conduit reinforced Ross procedure between 2009 and 2021 were reviewed. Most patients had a unicuspid or bicuspid aortic valve (n = 52; 85%), predominant aortic valve regurgitation (n = 42; 77%), and >30 mm dilatation of the ascending aorta (n = 33; 54%). A prior aortic valve procedure was noted in 47 patients (77%) patients, including 38 (62%) with surgical repair and 9 (15%) with balloon dilatation. The pulmonary autograft was reimplanted within a Dacron conduit with a median diameter of 25.6 mm (range, 20-30 mm) using the David valve-sparing aortic root replacement technique. Results All patients survived. The median age at surgery was 16.8 years (range, 6-38 years). Neo-aortic valve replacement was required in 3 patients (4.9%; 95% CI, 0.34%- 12.7%) because of infective endocarditis, left ventricular false aneurysm, and leaflet perforation, respectively; the repeat procedure was done early in 2 of these patients (2 of 61; 3%). Six patients required right ventricular outflow conduit replacement, 5 by surgery and 1 percutaneously. The median duration of follow-up was 90 months (range, 10-124 months). The 5- and 10-year rates of reintervention-free survival were 84.3% (95% CI, 74%-95%) and 81.6% (95% CI, 72%-93%), respectively, and 5-year survival without aortic reintervention was 94.5% (95% CI, 88%-100%), with little change at 10 years. No patients experienced deterioration of initial neo-aortic valve function (ie, regurgitation or stenosis). Conclusions Autograft reinforcement using the reimplantation technique allowed expansion of Ross procedure indications to all patients requiring aortic valve replacement and prevented neo-aortic root dilatation. Failures were uncommon. Long-term follow-up data showed stable neo-aortic valve function.
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Abeln KB, Schäfers S, Ehrlich T, Federspiel JM, Schäfers HJ. Ross Operation with Autologous External Autograft Stabilization - Long-term Results. Ann Thorac Surg 2021; 114:502-509. [PMID: 34678281 DOI: 10.1016/j.athoracsur.2021.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/17/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND We have proposed an external stabilization technique to minimize autograft dilatation after the Ross operation. The aim of this study was to analyze autograft function and root dimensions following root replacement with and without external root support. METHODS Between 10/1995 and 02/2021, 185 adult patients (73% male; age 38±9 years) underwent a Ross operation as full-root replacement with (n=136) or without support (n=49). Autograft function and root dimensions were determined echocardiographically. Median follow-up was 3.4[1.13-14.74] years; it was 95% complete. Survival and freedom from reoperation were calculated; changes in autograft root dimensions were analyzed using mixed-effect models. RESULTS Survival (95%) and freedom from autograft reoperation (94%) at 15 years were higher with than without support (p=0.003 or p=0.004). In the first five years, patients with support showed an indexed root size progression of 0.712mm/(year*m)(p=0.003) compared to 1.554mm/(year*m)(p=0.001) without. Progression rates were higher for patients without stabilization (p=0.045). After five years, progression rates were similar in both groups (0.248mm/(year*m)(p<0.001) with persistent difference between the groups. CONCLUSIONS The Ross procedure as full-root replacement is associated with a relevant rate of autograft dilatation and reoperation. The use of external root stabilization may reduce autograft dilatation and is associated with improved survival and durability.
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Affiliation(s)
- Karen B Abeln
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | | | - Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Jan M Federspiel
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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Whitlock R, Belley-Cote E, Rega F, Chu MWA, McClure GR, Hronyecz H, Verbrugghe P, Devereaux PJ, Bangdiwala S, Eikelboom J, Brady K, Sharifulin R, Bogachev-Prokophiev A, Stoica S. Ross for Valve replacement In AduLts (REVIVAL) pilot trial: rationale and design of a randomised controlled trial. BMJ Open 2021; 11:e046198. [PMID: 34531204 PMCID: PMC8449981 DOI: 10.1136/bmjopen-2020-046198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION In non-elderly adults, aortic valve replacement (AVR) with conventional prostheses yield poor long-term outcomes. Recent publications suggest a benefit of the Ross procedure over conventional AVR and highlight the need for high-quality randomised controlled trial (RCTs) on the optimal AVR. We have initiated a pilot trial assess two feasibility criteria and one assumption: (1) evaluate the capacity to enrol six patients per centre per year in at least five international centre, (2) validate greater than 90% compliance with allocation and (3) to validate the proportion of mechanical (≥65%) vs biological (≤35%) valves in the conventional arm. METHODS AND ANALYSIS Ross for Valve replacement In AduLts (REVIVAL) is a multinational, expertise-based RCT in adults aged 18-60 years undergoing AVR, comparing the Ross procedure versus one of the alternative approaches (mechanical vs stented or stentless bioprosthesis). The feasibility objectives will be assessed after randomising 60 patients; we will then make a decision regarding whether to expand the trial with the current protocol. We will ultimately examine the impact of the Ross procedure as compared with conventional AVR in non-elderly adults on survival free of valve-related life-threatening complications (major bleeding, systemic thromboembolism, valve thrombosis and valve reoperation) over the duration of follow-up. The objectives of the pilot trial will be analysed using descriptive statistics. In the full trial, the intention-to-treat principle will guide all primary analyses. A time-to-event analysis will be performed and Kaplan-Meier survival curves with comparison between groups using a log rank test will be presented. ETHICS AND DISSEMINATION REVIVAL will answer whether non-elderly adults benefit from the Ross procedure over conventional valve replacement. The final results at major meetings, journals, regional seminars, hospital rounds and via the Reducing Global Perioperative Risk Multimedia Resource Centre. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT03798782 PROTOCOL VERSION: January 29, 2019 (Final Version 1.0).
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Affiliation(s)
- Richard Whitlock
- Surgery, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Emilie Belley-Cote
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Filip Rega
- Department of Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Michael W A Chu
- Cardiac Surgery, University of Western Ontario Faculty of Health Sciences, London, Ontario, Canada
| | - Graham R McClure
- Surgery, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - Peter Verbrugghe
- Department of Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - P J Devereaux
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - John Eikelboom
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Katheryn Brady
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Ravil Sharifulin
- FSBI National Medical Research Center named after E N Meshalkin, Novosibirsk, Novosibirskaâ, Russian Federation
| | | | - Serban Stoica
- Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
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Varrica A, Satriano A, Frigiola A, Giamberti A. AUTOGRAFT WRAPPING REINFORCEMENT IN ADOLESCENTS UNDERWENT ROSS OPERATION: A TAILORED COAT. Ann Thorac Surg 2021; 114:866-871. [PMID: 34217690 DOI: 10.1016/j.athoracsur.2021.05.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/24/2021] [Accepted: 05/24/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Ross operation is a good surgical option for pediatric population with aortic valve disease. However, the need for reoperation due to aortic root dilatation remains the principal limitation of this procedure. We report a small series of adolescents who underwent the Ross operation with goretex membrane reinforcement to avoid the progressive dilatation of the neo-aortic root. METHODS Between March 2002 and March 2010, 15 adolescent patients underwent a modified Ross procedure with the autograft wrapping with Gore® Preclude® pericardial membrane 0.1 mm. Follow-up was performed by clinical and echocardiographic controls. RESULTS The mean age of these patients was 15 ± 1.4 years. The mean aortic cross-clamp time was 130 ± 17 minutes. The mean cardiopulmonary bypass time was 187 ± 27 minutes. There was no hospital mortality. The mean follow-up was 15 ± 2.5 years (range 9.7-17.7 years). During the follow-up one patient required aortic valve reoperation for cusps prolapse. The mean diameters of annulus (22.8 ± 1.8 mm vs 23.3 ± 1.5 mm, p=0.12), aortic root (27.4±1.4 mm vs 28.2 ± 0.8 mm, p=0.09) and sino-tubular junction (24.3 ± 1.1 mm vs 25.1 ± 0.7 mm, p=0.11) were not statistically different between discharge and follow up. CONCLUSIONS The wrapping reinforcement autograft in Ross procedure with goretex membrane is simple, safe and does not require significant additional time. Our results showed good early and long-term outcomes in terms of reoperation, aortic root dilatation and aortic valve degeneration.
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Affiliation(s)
- Alessandro Varrica
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy.
| | - Angela Satriano
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy
| | - Alessandro Frigiola
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy
| | - Alessandro Giamberti
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy
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Coselli JS. Commentary: Not just for kids anymore: The Ross procedure grows up. J Thorac Cardiovasc Surg 2020; 161:916-917. [PMID: 33454097 DOI: 10.1016/j.jtcvs.2020.12.032] [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: 12/02/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's-Baylor St Luke's Medical Center, Houston, Tex.
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Vanderveken E, Vastmans J, Verbelen T, Verbrugghe P, Famaey N, Verbeken E, Treasure T, Rega F. Reinforcing the pulmonary artery autograft in the aortic position with a textile mesh: a histological evaluation. Interact Cardiovasc Thorac Surg 2019; 27:566-573. [PMID: 29912400 DOI: 10.1093/icvts/ivy134] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/25/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The Ross procedure involves replacing a patient's diseased aortic valve with their own pulmonary valve. The most common failure mode is dilatation of the autograft. Various strategies to reinforce the autograft have been proposed. Personalized external aortic root support has been shown to be effective in stabilizing the aortic root in Marfan patients. In this study, the use of a similar external mesh to support a pulmonary artery autograft was evaluated. METHODS The pulmonary artery was translocated as an interposition autograft in the descending thoracic aortas of 10 sheep. The autograft was reinforced with a polyethylene terephthalate mesh (n = 7) or left unreinforced (n = 3). After 6 months, a computed tomography scan was taken, and the descending aorta was excised and histologically examined using the haematoxylin-eosin and Elastica van Gieson stains. RESULTS The autograft/aortic diameter ratio was 1.59 in the unreinforced group but much less in the reinforced group (1.11) (P < 0.05). A fibrotic sheet, variable in thickness and containing fibroblasts, neovessels and foreign body giant cells, was incorporated in the mesh. Histological examination of the reinforced autograft and the adjacent aorta revealed thinning of the vessel wall due to atrophy of the smooth muscle cells. Potential spaces between the vessel wall and the mesh were filled with oedema. CONCLUSIONS Reinforcing an interposition pulmonary autograft in the descending aorta with a macroporous mesh showed promising results in limiting autograft dilatation in this sheep model. Histological evaluation revealed atrophy of the smooth muscle cell and consequently thinning of the vessel wall within the mesh support.
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Affiliation(s)
- Emma Vanderveken
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Julie Vastmans
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Eric Verbeken
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Tom Treasure
- Clinical Operational Research Unit, UCL, London, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Expanding Eligibility for the Ross Procedure: A Reasonable Proposition? Can J Cardiol 2018; 34:759-765. [PMID: 29716763 DOI: 10.1016/j.cjca.2018.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/21/2018] [Accepted: 01/21/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although the Ross procedure offers potential benefits in young adults, technical complexity represents a significant limitation. Therefore, the safety of expanding its use in more complex settings is uncertain. The aim of this study was to compare early outcomes of standard isolated Ross procedures vs expanding elgibility to higher-risk clinical settings. METHODS From 2011 to 2016, 261 patients (46 ± 12 years) underwent Ross procedures in 2 centres. Patients were divided into 2 groups: standard Ross (n = 166) and expanded eligibility Ross (n = 95). Inclusion criteria for the expanded eligibility group were previous cardiac surgery, acute aortic valve endocarditis, severely impaired left ventricular (LV) function and patients undergoing concomitant procedures. All data were prospectively collected and are 100% complete. RESULTS Hospital mortality was 0% in the standard group (0/166) vs 2% in the expanded eligibility group (2/95) (P = 0.13). Sixteen patients (10%) developed acute renal injury in the standard group vs 13 (14%) patients in the expanded eligibility group (P = 0.31). There were no postoperative myocardial infarctions, no neurological events, and no infectious complications. Median intensive care unit (ICU) stay in the standard group was 2 vs 3 days in the expanded eligibility group (P = 0.004), whereas median hospital stay was 6 vs 7 days, respectively (range: 3-19 days) (P < 0.001). CONCLUSION Aside from longer ICU and hospital lengths of stay after the Ross procedure in higher-risk clinical scenarios, perioperative mortality and morbidity is similar to standard Ross procedures. Expanding the use of the Ross operation in young adults is a safe alternative in centres of expertise.
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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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Heidary Rouchi A, Radmehr H, Tavakoli SA, Jafarzadeh Kashi TS, Mahdavi-Mazdeh M. Iranian homograft heart valves: assessment of durability and late outcome. Cell Tissue Bank 2016; 17:603-610. [PMID: 27501816 DOI: 10.1007/s10561-016-9573-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/29/2016] [Indexed: 11/26/2022]
Abstract
Durability and the rate of complications of homograft heart valves, adjusted for patient-related contributors and surgical techniques, rely mainly on the quality of allografts which in turn are mirrored in the donor characteristics and most importantly recovery and processing procedures. Aimed to assess the quality, a study was conducted to figure out the durability and late outcome following homograft replacement with valved conduits procured by the Iranian Tissue Bank. Retrospectively, the pre-implantation, perioperative and follow-up data of 400 non-consecutive recipients of cryopreserved heart valves (222 pulmonary and 178 aortic) from 2006 to 2015 were collected and analyzed in terms of variables reflecting late outcome including adverse events and durability. In the context of durability, the event of interest was defined as the need for homograft replacement and homograft-related death. The mean follow-up time (SD) of study entrants (male/female ratio, 1.4) was 49.8 (36.3) months. Median age at the time of implantation was 11 years. Total 10-years mortality was 21 % (84/400), including 66.7 % early (30-days mortality: 56/84) and 33.3 % late (28/84). Overall late complication rate was 2 %. Median survival time was 120 months (95 % CI 83.3-156.6). The pulmonary valves appeared to be more durable (P value <0.001) and survival probabilities in small sized grafts were lower (P value 0.008). One-, five-, and ten-year graft survival was 82, 76 and 73 %, respectively. The evidences suggest that the homografts function satisfactory with low rate of late complications; nevertheless, more emphasis should be given to make long-term durability comparable.
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Affiliation(s)
- Alireza Heidary Rouchi
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Blvd., Tehran, 1419731351, Iran
| | - Hassan Radmehr
- Department of Cardiac Surgery, Children Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Amirhosein Tavakoli
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Blvd., Tehran, 1419731351, Iran
| | | | - Mitra Mahdavi-Mazdeh
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Blvd., Tehran, 1419731351, Iran.
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Nappi F, Carotenuto AR, Cutolo A, Fouret P, Acar C, Chachques JC, Fraldi M. Compliance mismatch and compressive wall stresses drive anomalous remodelling of pulmonary trunks reinforced with Dacron grafts. J Mech Behav Biomed Mater 2016; 63:287-302. [PMID: 27442920 DOI: 10.1016/j.jmbbm.2016.06.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/20/2016] [Accepted: 06/26/2016] [Indexed: 11/18/2022]
Abstract
Synthetic grafts are often satisfactory employed in cardiac and vascular surgery, including expanded poly(ethylene terephthalate) or expanded poly(tetrafluoroethylene). However, accumulating evidences suggest the emergence of worrisome issues concerning the long-term fate of prosthetic grafts as large vessel replacement. Disadvantages related to the use of synthetic grafts can be traced in their inability of mimicking the elasto-mechanical characteristics of the native vascular tissue, local suture overstress leading to several prosthesis-related complications and retrograde deleterious effects on valve competence, cardiac function and perfusion. Motivated by this, in the present work it is analyzed - by means of both elemental biomechanical paradigms and more accurate in silico Finite Element simulations - the physical interaction among aorta, autograft and widely adopted synthetic (Dacron) prostheses utilized in transposition of pulmonary artery, highlighting the crucial role played by somehow unexpected stress fields kindled in the vessel walls and around suture regions, which could be traced as prodromal to the triggering of anomalous remodelling processes and alterations of needed surgical outcomes. Theoretical results are finally compared with histological and surgical data related to a significant experimental animal campaign conducted by performing pulmonary artery transpositions in 30 two-month old growing lambs, followed up during growth for six months. The in vivo observations demonstrate the effectiveness of the proposed biomechanical hypothesis and open the way for possible engineering-guided strategies to support and optimize surgical procedures.
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Affiliation(s)
- Francesco Nappi
- Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Angelo Rosario Carotenuto
- Department of Chemical, Materials and Production Engineering of the University of Naples Federico II, Italy
| | - Arsenio Cutolo
- Department of Structures for Engineering and Architecture of the University of Naples Federico II, Italy
| | - Pierre Fouret
- Department of Pathology, Hôpital de la Salpétriere, Paris, France
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hôpital de la Salpétriere, Paris, France
| | - Juan Carlos Chachques
- Laboratory of Biosurgical Research "Carpentier Foundation", Pompidou Hospital, University Paris Descartes, France
| | - Massimiliano Fraldi
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, University of Napoli Federico II, Italy.
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Mookhoek A, de Kerchove L, El Khoury G, Weimar T, Luciani GB, Mazzucco A, Bogers AJ, Aicher D, Schäfers HJ, Charitos EI, Stierle U, Takkenberg JJ. European multicenter experience with valve-sparing reoperations after the Ross procedure. J Thorac Cardiovasc Surg 2015; 150:1132-7. [DOI: 10.1016/j.jtcvs.2015.08.043] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 08/02/2015] [Accepted: 08/12/2015] [Indexed: 11/30/2022]
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A composite semiresorbable armoured scaffold stabilizes pulmonary autograft after the Ross operation: Mr Ross's dream fulfilled. J Thorac Cardiovasc Surg 2015; 151:155-64.e1. [PMID: 26602900 DOI: 10.1016/j.jtcvs.2015.09.084] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 08/10/2015] [Accepted: 09/12/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Use of resorbable external reinforcement of the pulmonary autograft during the Ross operation has been suggested, but the differential regional potential for dilation of the aorta, mainly regarding the neo-root and the neo-Valsalva sinuses, represents an unresolved issue. Auxetic materials could be useful in preventing dilation given their favorable mechanical properties. We designed a composite semiresorbable armoured bioprosthesis constituted by polydioxanone and expanded polytetrafluoroethylene and evaluated its effectiveness as a pulmonary autograft reinforcement device in an animal model of the Ross procedure. METHODS An experimental model of the Ross procedure was performed in 20 three-month-old growing lambs. The pulmonary autograft was alternatively nonreinforced (control group n = 10) or reinforced with composite bioprosthesis (reinforced group n = 10). Animals were followed up during growth for 6 months by angiography and echocardiography. Specific stainings for extracellular matrix and immunohistochemistry for metalloproteinase-9 were performed. RESULTS Reference aortic diameter increased from 14 ± 1 mm to 19 ± 2 mm over 6 months of growth. In the control group, pulmonary autograft distension (28 ± 2 mm) was immediately noted, followed by aneurysm development at 6 months (40 ± 2 mm, P < .001 vs reference). In the reinforced group, an initial dilation to 18 ± 1 mm was detected and the final diameter was 27 ± 2 mm (42% increase). Two deaths due to pulmonary autograft rupture occurred in the control group. On histology, the control group showed medial disruption with connective fibrous replacement, whereas in the reinforced group compensatory intimal hyperplasia was present in the absence of intimal tears. The bioprosthesis promoted a positive matrix rearrangement process favoring neoarterialization and elastic remodeling as demonstrated on specific staining for elastin collagen and metalloproteinase-9. CONCLUSIONS The device adapted and functionally compensated for the characteristics of autograft growth, guaranteeing a reasonable size of the autograft at 6 months, but more important, because the device is biocompatible, it did not disrupt the biological process of growth or cause inflammatory damage to the wall.
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Gillespie MJ, McElhinney DB, Kreutzer J, Hellenbrand WE, El-Said H, Ewert P, Rhodes JF, Søndergaard L, Jones TK. Transcatheter Pulmonary Valve Replacement for Right Ventricular Outflow Tract Conduit Dysfunction After the Ross Procedure. Ann Thorac Surg 2015; 100:996-1002; discussion 1002-3. [DOI: 10.1016/j.athoracsur.2015.04.108] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 04/10/2015] [Accepted: 04/15/2015] [Indexed: 11/16/2022]
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Ross procedure in the setting of anomalous aortic origin of a coronary artery. J Thorac Cardiovasc Surg 2015; 150:1000-2. [PMID: 26277473 DOI: 10.1016/j.jtcvs.2015.07.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/03/2015] [Accepted: 07/17/2015] [Indexed: 11/23/2022]
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Cheung DY, Duan B, Butcher JT. Current progress in tissue engineering of heart valves: multiscale problems, multiscale solutions. Expert Opin Biol Ther 2015; 15:1155-72. [PMID: 26027436 DOI: 10.1517/14712598.2015.1051527] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Heart valve disease is an increasingly prevalent and clinically serious condition. There are no clinically effective biological diagnostics or treatment strategies. The only recourse available is replacement with a prosthetic valve, but the inability of these devices to grow or respond biologically to their environments necessitates multiple resizing surgeries and life-long coagulation treatment, especially in children. Tissue engineering has a unique opportunity to impact heart valve disease by providing a living valve conduit, capable of growth and biological integration. AREAS COVERED This review will cover current tissue engineering strategies in fabricating heart valves and their progress towards the clinic, including molded scaffolds using naturally derived or synthetic polymers, decellularization, electrospinning, 3D bioprinting, hybrid techniques, and in vivo engineering. EXPERT OPINION Whereas much progress has been made to create functional living heart valves, a clinically viable product is not yet realized. The next leap in engineered living heart valves will require a deeper understanding of how the natural multi-scale structural and biological heterogeneity of the tissue ensures its efficient function. Related, improved fabrication strategies must be developed that can replicate this de novo complexity, which is likely instructive for appropriate cell differentiation and remodeling whether seeded with autologous stem cells in vitro or endogenously recruited cells.
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Affiliation(s)
- Daniel Y Cheung
- Cornell University, Department of Biomedical Engineering , Ithaca, NY , USA
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Spadaccio C, Montagnani S, Acar C, Nappi F. Introducing bioresorbable scaffolds into the show. A potential adjunct to resuscitate Ross procedure. Int J Cardiol 2015; 190:50-2. [PMID: 25912121 DOI: 10.1016/j.ijcard.2015.04.098] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Stefania Montagnani
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hôpital de la Salpétrière, Paris, France
| | - Francesco Nappi
- Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, Paris, France.
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Kallio M, Pihkala J, Sairanen H, Mattila I. Long-term results of the Ross procedure in a population-based follow-up. Eur J Cardiothorac Surg 2015; 47:e164-70. [PMID: 25661074 DOI: 10.1093/ejcts/ezv004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/02/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the long-term outcomes of the Ross procedure in a nationwide follow-up. METHODS This retrospective study involved all children treated with the Ross procedure in Finland between 1994 and 2009. The clinical records were reviewed for demographic and anatomical characteristics, Ross operation data, surgical history and status at the latest follow-up. The median follow-up time was 11.5 (range 2.4-19.2) years. RESULTS Fifty-one patients underwent either the Ross (n = 37) or the Ross-Konno (n = 14) procedure at a median age of 4.8 (range 0.02-16.3) years, including 13 infants (<1 year of age). The indication for the Ross procedure was aortic valve stenosis, regurgitation or both, which was observed in 29, 24 and 47% of patients, respectively. The early mortality (before hospital discharge) rate was 10% (31% in infants) and the late mortality rate 6% (15% in infants). Higher mortality was discovered in patients treated with the Ross-Konno procedure (P = 0.001). The most common cause for reintervention was pulmonary homograft stenosis. The rate of freedom from right ventricular outflow tract reintervention was 98% at 5 years, 83% at 10 years and 59% at 15 years. The rate of freedom from autograft reintervention was 98% at 5 and 10 years, and 81% at 15 years. At the latest follow-up visit, mild-to-moderate aortic root dilatation was reported in 52% of patients, and 4 patients had undergone autograft-related reinterventions. Trivial autograft valve regurgitation was commonly seen, but only 1 patient developed severe autograft regurgitation requiring mechanical valve replacement 15.9 years after the Ross operation. CONCLUSIONS The most common reason for reintervention after the Ross procedure in children is homograft stenosis. Aortic root dilatation and autograft valve regurgitation are relatively common but rarely lead to reinterventions before adulthood. Intraoperative complications and complex cardiac anatomy are associated with high mortality in infants undergoing the Ross-Konno procedure. In our centre, the Ross procedure has provided good long-term results in this challenging group of paediatric patients.
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Affiliation(s)
- Merja Kallio
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland
| | - Jaana Pihkala
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland
| | - Heikki Sairanen
- Department of Pediatric and Transplantation Surgery, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland
| | - Ilkka Mattila
- Department of Pediatric and Transplantation Surgery, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Helsinki, Finland
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Liebrich M, Weimar T, Tzanavaros I, Roser D, Doll KN, Hemmer WB. The David Procedure for Salvage of a Failing Autograft After the Ross Operation. Ann Thorac Surg 2014; 98:2046-52. [DOI: 10.1016/j.athoracsur.2014.06.065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 06/14/2014] [Accepted: 06/24/2014] [Indexed: 10/24/2022]
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Zebele C, Chivasso P, Sedmakov C, Angelini G, Caputo M, Parry A, Stoica S. The Ross Operation in Children and Young Adults. World J Pediatr Congenit Heart Surg 2014; 5:406-12. [DOI: 10.1177/2150135114537532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/28/2014] [Indexed: 11/17/2022]
Abstract
Objectives: To determine UK national trends and results of the Ross operation in relation to all aortic valve interventions. Methods: Examination of the UK Congenital Central Cardiac Audit Database for all aortic valve procedures performed between 2000 and 2011 in children (0-16 years) and young adults (16-30 years). Results: A total of 2,206 aortic valve procedures were performed in children and 1,824 in young adults, the proportions in the two groups being: Ross operation (19% vs 15%, respectively), surgical valvoplasty (9.5% vs 4%), surgical valvotomy (9.5% vs 1%), aortic valve replacement (AVR; 11% vs 55%), aortic root replacement (4% vs 18%), and balloon valvoplasty (47% vs 7%). The 30-day and 1-year survival after Ross is 99.3% and 98.7%, respectively, in the last four years achieving 100%. In children, the proportion of balloon valvoplasty increased from an average of 43% in 2000 to 2006 to 53% in 2007 to 2011, whereas the Ross operation decreased from 22% to 16% ( P < .001). In young adults, the figures are an increase from 49% to 58% for AVR compared to a decrease from 23% to 9% for Ross ( P < .001). Our own single-center series of 91 patients also shows standard results for early- and long-term survival and freedom from reoperation, but gradually fewer Ross operations performed. The year-on-year changes show a significant decreasing trend locally and nationally. Conclusions: Despite an excellent track record, the Ross operation is performed less frequently in the United Kingdom. This report is a first step in comparing treatment modalities at national level.
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Affiliation(s)
- Carlo Zebele
- Children’s Hospital, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Pierpaolo Chivasso
- Children’s Hospital, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Christo Sedmakov
- Children’s Hospital, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Gianni Angelini
- Children’s Hospital, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
- Imperial College, London, United Kingdom
| | - Massimo Caputo
- Children’s Hospital, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
- Rush University Medical Center, Chicago, IL, USA
| | - Andrew Parry
- Children’s Hospital, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Serban Stoica
- Children’s Hospital, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
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Abstract
In 1967, Donald Ross transferred the patient's own pulmonary valve into the aortic root. Although results of this technique were encouraging, the Ross procedure did not gain widespread popularity until the late 1980s when surgeons started to implant the pulmonary autograft as a freestanding full root replacement with reimplantation of the coronary arteries. However, frequent dilatation of the pulmonary autograft was observed using the freestanding full root replacement technique. In contrast, the original subcoronary implantation technique and aortic root inclusion technique prevented dilatation in the long-term. Through advancing know-how in aortic root surgery and confidence, the Ross procedure has also been used in combined procedures and complex clinical presentations with good long-term results, which encourage continual use. However, the Ross procedure is a complex operation; careful patient selection and experience of the surgeon are mandatory requirements to achieve satisfactory results.
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Affiliation(s)
- Alexander Weymann
- Department of Cardiac Surgery, Heart and Marfan Center - University of Heidelberg, INF 110, 69120 Heidelberg, Germany
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Consensus on timing of intervention for common congenital heart diseases: part I - acyanotic heart defects. Indian J Pediatr 2013; 80:32-8. [PMID: 22752706 DOI: 10.1007/s12098-012-0833-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 06/14/2012] [Indexed: 12/15/2022]
Abstract
The purpose of this review/editorial is to discuss how and when to treat the most common acyanotic congenital heart defects (CHD); the discussion of cyanotic heart defects will be presented in a subsequent editorial. By and large, the indications and timing of intervention are decided by the severity of the lesion. Balloon pulmonary valvuloplasty is the treatment of choice for valvar pulmonary stenosis and the indication for intervention is peak-to-peak systolic pressure gradient >50 mmHg across the pulmonary valve. For aortic valve stenosis, balloon aortic valvuloplasty appears to be the first therapeutic procedure of choice; the indications for balloon dilatation of aortic valve are peak-to-peak systolic pressure gradient across the aortic valve in excess of 70 mmHg irrespective of the symptoms or a gradient ≥ 50 mmHg with either symptoms or electrocardiographic ST-T wave changes indicative of myocardial perfusion abnormality. The indications for intervention in coarctation of the aorta are significant hypertension and/or congestive heart failure along with a pressure gradient in excess of 20 mmHg across the coarctation; the type of intervention varies with age at presentation and the anatomy of coarctation: surgical intervention for neonates and young infants, balloon angioplasty for discrete native coarctation in children, and stents in adolescents and adults. Long segment coarctations or those associated with hypoplasia of the isthmus or transverse aortic arch require surgical treatment in younger children and stents in adolescents and adults. For post-surgical aortic recoarctation, balloon angioplasty in young children and stents in adolescents and adults are treatment options. Transcatheter closure methods are currently preferred for ostium secundum atrial septal defects (ASDs); the indications for occlusion are right ventricular volume overload by echocardiogram. Ostium primum, sinus venosus and coronary sinus ASDs require surgical closure. For all ASDs elective closure around age 4 to 5 y is recommended or as and when detected beyond that age. For the more common perimembraneous ventricular septal defects (VSDs) of large size, surgical closure should be performed prior to 6 to 12 mo of age. Muscular VSDs may be closed with devices. Patent ductus arteriosus (PDA) may be closed with Amplatzer Duct Occluder if they are moderate to large and Gianturco coils if they are small. Surgical and video-thoracoscopic closure are the available options at some centers. In the presence of pulmonary hypertension appropriate testing to determine suitability for closure should be undertaken. The treatment of acyanotic CHD with currently available medical, transcatheter and surgical methods is feasible, safe and effective and should be performed at an appropriate age in order to prevent damage to cardiovascular structures.
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Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: An update on the German Dutch Ross Registry. J Thorac Cardiovasc Surg 2012; 144:813-21; discussion 821-3. [DOI: 10.1016/j.jtcvs.2012.07.005] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 05/24/2012] [Accepted: 07/09/2012] [Indexed: 11/21/2022]
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