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Penov K, Haugen MA, Radakovic D, Hamouda K, Gorski A, Leyh R, Bening C. Decellularized Pulmonary Xenograft Matrix PplusN versus Cryopreserved Homograft for RVOT Reconstruction during Ross Procedure in Adults. Thorac Cardiovasc Surg 2024; 72:205-213. [PMID: 34972237 DOI: 10.1055/s-0041-1740539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Decellularized pulmonary homografts are being increasingly adopted for right ventricular outflow tract reconstruction in adult patients undergoing the Ross procedure. Few reports presented Matrix PplusN xenograft (Matrix) in a negative light. The objective of this study was to compare our midterm outcomes of Matrix xenograft versus standard cryopreserved pulmonary homograft (CPHG). METHODS Eighteen patients received Matrix xenograft between January 2012 and June 2016, whereas 66 patients received CPHG. Using nonparametric statistical tests and survival analysis, we compared midterm echocardiographic and clinical outcomes between the groups. RESULTS Except for significant age difference (the Matrix group was significantly older with 57 ± 8 years than the CPHG group, 48 ± 9 years, p = 0.02), the groups were similar in all other baseline characteristics. There were no significant differences in cardiopulmonary bypass times (208.3 ± 32.1 vs. 202.8 ± 34.8) or in cross-clamp times (174 ± 33.9 vs. 184.4 ± 31.1) for Matrix and CPHG, respectively. The Matrix group had significantly inferior freedom from reintervention than the CPHG group with 77.8 versus 98.5% (p = 0.02). Freedom from pulmonary valve regurgitation ≥ 2 was not significantly different between the groups with 82.4 versus 90.5% for Matrix versus CPHG, respectively. After median follow-up of 4.9 years, Matrix xenograft developed significantly higher peak pressure gradients compared with CPHG (20.4 ± 15.5 vs. 12.2 ± 9.0 mm Hg; p = 0.04). CONCLUSION After 5 years of clinical and echocardiographic follow-up, the decellularized Matrix xenograft had inferior freedom from reintervention compared with the standard CPHG. Closer follow-up is necessary to avoid progression of valve failure into right ventricular deterioration.
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Affiliation(s)
- Kiril Penov
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | | | - Dejan Radakovic
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Khaled Hamouda
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Armin Gorski
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Rainer Leyh
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Constanze Bening
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
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Diaz-Castrillon CE, Viegas M, Castro-Medina M, Punu K, Tarun S, DaSilva Da Fonseca L, Morell V. Pulmonary Homograft vs Handmade Polytetrafluoroethylene-Valved Conduits After the Ross Procedure. Ann Thorac Surg 2023; 116:980-986. [PMID: 37429515 DOI: 10.1016/j.athoracsur.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND This study aimed to longitudinally compare expanded polytetrafluoroethylene (ePTFE)-valved conduits vs pulmonary homograft (PH) conduits after right ventricular outflow tract reconstruction in the Ross procedure. METHODS Patients undergoing a Ross procedure from June 2004 to December 2021 were identified. Echocardiographic data, catheter-based interventions, or conduit replacements, as well as time to first reintervention or replacement, were comparatively assessed between handmade ePTFE-valved conduits and PH conduits. RESULTS A total of 90 patients were identified. The median age and weight were 13.8 years (interquartile range [IQR], 8.08-17.80 years) and 48.3 kg (IQR, 26.8-68.7 kg), respectively. There were 66% (n = 60) ePTFE-valved conduits and 33% (n = 30) PHs. The median size was 22 mm (IQR, 18-24 mm) for ePTFE-valved conduits and 25 mm (IQR, 23-26 mm) for PH conduits (P < .001). Conduit type had no differential effect in the gradient evolution or the odds of presenting with severe regurgitation in the last follow-up echocardiogram. Of the 26 first reinterventions, 81% were catheter-based interventions, without statistically significant differences between the groups (69% PH vs 83% ePTFE). The overall surgical conduit replacement rate was 15% (n = 14), and it was higher in the homograft group (30% vs 8%; P = .008). However, conduit type was not associated with an increased hazard for reintervention or reoperation after adjusting for covariates. CONCLUSIONS Right ventricular outflow tract reconstruction using handmade ePTFE-valved conduits after a Ross procedure provides encouraging midterm results, without a differential effect in hemodynamic performance or valve function compared with PH conduits. These results are reassuring about the use of handmade valved conduits in pediatric and young adult patients. Longer follow-up of tricuspid conduits will complement valve competency assessment.
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Affiliation(s)
- Carlos E Diaz-Castrillon
- Division of Pediatric Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melita Viegas
- Division of Pediatric Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Mario Castro-Medina
- Division of Pediatric Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kristian Punu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shwetabh Tarun
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Luciana DaSilva Da Fonseca
- Division of Pediatric Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Victor Morell
- Division of Pediatric Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Reply: Risk of Endocarditis Extension in Ross Reintervention With Transcatheter Pulmonary Valve Replacement. J Am Coll Cardiol 2022; 79:e459. [PMID: 35618355 DOI: 10.1016/j.jacc.2022.03.360] [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: 03/07/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022]
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Skillington P, Tripathy AK, Keefe MO, Larobina M. Right-sided reconstruction during the Ross procedure—A technical perspective for long-term durability. JTCVS Tech 2021; 10:403-407. [PMID: 34984396 PMCID: PMC8691921 DOI: 10.1016/j.xjtc.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
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Fujita B, Aboud A, Sievers HH, Ensminger S. State-of-the-art: Insights from the Ross Registry. JTCVS Tech 2021; 10:396-400. [PMID: 34977764 PMCID: PMC8690870 DOI: 10.1016/j.xjtc.2021.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/04/2021] [Indexed: 11/04/2022] Open
Abstract
The treatment of aortic valve disease in young patients is still a major clinical challenge, as the pre-eminent emphasis is on durability and long-term outcomes beyond 10 to 15 years, sometimes >20 to 30 years. The Ross procedure uses the autologous pulmonary valve as an aortic valve substitute and aims to improve valve durability while avoiding anticoagulation and therefore achieve a sustained long-term result with regard to survival, valve functionality, and quality of life. However, this procedure is technically demanding and only performed at a low frequency. Data investigating the Ross procedure are mostly limited to observational studies from single expert centers, while sufficient randomized data are almost completely lacking. Therefore, to create a clinically relevant database of this therapy, the multicenter Ross Registry was founded in 2001. New patients were included, follow-up of past patients continuously updated, and outcomes regularly reported. Throughout recent years, numerous analyses have been performed to characterize this patient population, surgical techniques, risk factors for morbidity and mortality, and most importantly survival outcomes. Currently, more than 2500 patients are included, and the long-term follow-up has reached >25 years in the very first patients who were included. In the most recent study, 2444 adult patients with a mean age of 44.1 ± 11.7 years were analyzed, and it showed that excellent mid-term survival is maintained after 25 years. In addition, the rate of reintervention was lower than reported in patients with xenografts and anticoagulation-related morbidity lower than reported in patients with mechanical valves. In the absence of robust randomized controlled trials, registry data are very important to monitor outcomes and mirror the quality of current practice. Therefore, the Ross Registry provides a unique and important data base regarding treatment of aortic valve disease in young patients.
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Hongu H, Yamagishi M, Maeda Y, Itatani K, Fujita S, Nakatsuji H, Yaku H. Expanded Polytetrafluoroethylene Conduits With Bulging Sinuses and a Fan-Shaped Valve in Right Ventricular Outflow Tract Reconstruction. Semin Thorac Cardiovasc Surg 2021; 34:972-980. [PMID: 33691193 DOI: 10.1053/j.semtcvs.2021.02.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/01/2021] [Indexed: 01/08/2023]
Abstract
We developed a handmade expanded polytetrafluoroethylene (ePTFE) pulmonary valvular conduit (PVC) with bulging sinuses and a fan-shaped ePTFE valve for right ventricular outflow tract (RVOT) reconstruction. We aimed to investigate the results of this device in this multicenter study. From 2001 to 2020, 1776 patients underwent RVOT reconstruction using ePTFE PVCs at 65 institutions in Japan. The median age and body weight were 4.1 years (range, 3 days to 67.1 years) and 13.3 (range, 1.8-91.3) kg, respectively. The median PVC size was 18 (range, 8-24) mm. The median Z-value of the ePTFE PVC was 1.1 (range, -3.8 to 5.0). The ePTFE PVC conditions were investigated by cardiac echocardiography and catheterization. The median follow-up period was 3.3 years (range, 0 day to 16.2 years). There were only 9 cases (0.5%) with PVC-related unknown deaths. Reintervention was performed in 283 patients (15.9%), and 190 patients (10.7%) required explantation. Freedom from reintervention and explantation at 5/10 years were 86.7/61.5% and 93.0/69.1%, respectively. At the latest echocardiography, PVC regurgitation grade was better than mild in 88.4% patients. The average peak RVOT gradient was 15.7 ± 15.9 mm Hg at the latest cardiac catheterization. ePTFE PVC infection was detected in only 8 patients (0.5%). Relative stenosis due to somatic growth was the most common cause of PVC explantation. The performance of ePTFE in terms of durability, valvular performance, and the resistance against infection is considerable and may replace conventional prosthetic materials. Further improvement of the ePTFE membrane is essential to prevent valvular dysfunction.
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Affiliation(s)
- Hisayuki Hongu
- Department of Pediatric Cardiovascular surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Itatani
- Department of Pediatric Cardiovascular surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shuhei Fujita
- Department of Pediatric Cardiovascular surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroki Nakatsuji
- Department of Pediatric Cardiovascular surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Division of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Sharifulin R, Bogachev-Prokophiev A, Demin I, Afanasyev A, Ovcharov M, Pivkin A, Sapegin A, Zhuravleva I, Karaskov A. Allografts and xenografts for right ventricular outflow tract reconstruction in Ross patients. Eur J Cardiothorac Surg 2021; 59:162-169. [PMID: 32864698 DOI: 10.1093/ejcts/ezaa244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/30/2020] [Accepted: 06/04/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Pulmonary allografts (AG) are the gold standard for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure. However, there is limited availability of AG in some countries, and the use of alternative grafts for RVOT reconstruction remains controversial. This study aimed to compare the rates of freedom from RVOT graft dysfunction for AG and diepoxide-treated pericardial xenografts (DPXG). METHODS Between 1998 and 2015, 793 adult patients underwent the Ross procedure in our centre. Using propensity score matching, the clinical outcomes and echocardiographic results of AG and DPXG were compared. RESULTS Propensity score matching resulted in 2 groups (AG and DPXG) of 122 patients each. No difference was found in early mortality (2.5%) in both groups. The freedom from RVOT graft dysfunction curves were comparable between the AG and DPXG groups (P = 0.186) and the 8-year rates of freedom from graft dysfunction were 91.8% and 82.2%, respectively. The survival rates at 8 years were 90.5% and 90.1%, and the rates of freedom from RVOT reintervention at 8 years were 100% and 96.8% for the AG and DPXG groups, respectively. At discharge and follow-up, transprosthetic gradients were significantly higher in the DPXG group. The rate of the RVOT gradient progression was also higher in the DPXG group than in the AG group (1.80 ± 0.06 vs 1.39 ± 0.04 mmHg/year, P < 0.001). CONCLUSIONS There was no difference in freedom from RVOT graft dysfunction by 8 years when using AG and DPXG in adult Ross patients, nor in survival and freedom from RVOT conduit reintervention. Long-term results need further evaluation.
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Affiliation(s)
- Ravil Sharifulin
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | | | - Igor Demin
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Alexander Afanasyev
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Mikhail Ovcharov
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Alexey Pivkin
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Andrey Sapegin
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Irina Zhuravleva
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Alexander Karaskov
- Heart Valve Surgery Department, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia
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Takigami M, Itatani K, Nakanishi N, Morichi H, Nishino T, Miyazaki S, Nakaji K, Yamano M, Kajiyama Y, Maeda Y, Matoba S, Yaku H, Yamagishi M. Reconstruction of right ventricular outflow tract stenosis and right ventricular failure after Ross procedure - comprehensive assessment of adult congenital heart disease with four-dimensional imaging: a case report. J Med Case Rep 2020; 14:113. [PMID: 32698864 PMCID: PMC7376682 DOI: 10.1186/s13256-020-02414-9] [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: 06/28/2019] [Accepted: 05/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Re-intervention after Ross procedure into the right ventricular outflow tract might be needed in patients in the long term. However, right ventricular outflow tract re-intervention indications are still unclear. Comprehensive assessment of total hemodynamics is needed. A 42-year-old Japanese woman was referred to our hospital for moderately severe pulmonary regurgitation and severe tricuspid regurgitation after a Ross-Konno procedure. Thirteen years after surgery, she developed atrial fibrillation and atrial flutter and complained of dyspnea. Electrophysiological studies showed re-entry circuit around the low voltage area of the lateral wall on the right atrium. Four-dimensional flow magnetic resonance imaging revealed moderate pulmonary regurgitation, severe tricuspid regurgitation, and a dilated right ventricle. Flow energy loss in right ventricle calculated from four-dimensional flow magnetic resonance imaging was five times higher than in normal controls, suggesting an overload of the right-sided heart system. Her left ventricular ejection fraction was almost preserved. Moreover, the total left interventricular pressure difference, which shows diastolic function, revealed that her sucking force in left ventricle was preserved. After the comprehensive assessments, we performed right ventricular outflow tract reconstruction, tricuspid valve annuloplasty, and right-side Maze procedure. A permanent pacemaker with a single atrial lead was implanted 14 days postoperatively. She was discharged 27 days postoperatively. Echocardiography performed 3 months later showed that the size of the dilated right ventricle had significantly reduced. DISCUSSION A four-dimensional imaging tool can be useful in the decision of re-operation in patients with complex adult congenital heart disease. The optimal timing of surgery should be considered comprehensively.
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Affiliation(s)
- Masao Takigami
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroko Morichi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | | | - Kosuke Nakaji
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Michiyo Yamano
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yo Kajiyama
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Chauvette V, Bouhout I, Tarabzoni M, Pham M, Wong D, Whitlock R, Chu MWA, El-Hamamsy I. Pulmonary homograft dysfunction after the Ross procedure using decellularized homografts-a multicenter study. J Thorac Cardiovasc Surg 2020; 163:1296-1305.e3. [PMID: 32888704 DOI: 10.1016/j.jtcvs.2020.06.139] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/28/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Pulmonary homograft dysfunction is a limitation after the Ross procedure. Decellularized pulmonary homografts can potentially mitigate this complication. The aim of this study was to examine the incidence, predictors, progression, and morphology of pulmonary homograft dysfunction using data from the Canadian Ross Registry. METHODS From 2011 to 2019, 466 consecutive patients (mean age: 47 ± 12 years, 73% male) underwent a Ross procedure using a decellularized cryopreserved pulmonary homograft (SynerGraft SG; CryoKife, Kennesaw, Ga). Pulmonary homograft dysfunction was defined as any of the following: peak pulmonary gradient ≥30 mm Hg, pulmonary regurgitation >2, or pulmonary homograft reintervention. Patients meeting ≥1 of these criteria (n = 30) were compared with the rest of the cohort (n = 436). Median follow-up is 2.2 years (maximum = 8.5 years) and 99% complete (1176 patient-years). RESULTS The cumulative incidence of pulmonary homograft dysfunction was 11 ± 2% at 6 years. Pulmonary homograft stenosis was the most frequent presentation (n = 28 patients, 93%). Morphologically, stenosis occurred most often along the conduit (59%). Overall, 4 patients required homograft reintervention. At 6 years, the cumulative incidence of homograft reintervention was 3 ± 1%. The instantaneous risk was greatest in the first year after surgery (3.5%/year) and decreased to <1%/year thereafter. Patient age <45 years was the only independent risk factor associated with pulmonary homograft dysfunction (hazard ratio, 3.1, 95% confidence interval, 1.1-8.6, P = .03). CONCLUSIONS The use of decellularized cryopreserved pulmonary homografts results in a low incidence of dysfunction and reintervention after the Ross procedure. The risk is greater in the first postoperative year. Younger age is the only independent risk factor for pulmonary homograft dysfunction.
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Affiliation(s)
- Vincent Chauvette
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Ismail Bouhout
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Mohammed Tarabzoni
- Department of Cardiac Surgery, London Health Science Center, Western University, London, Ontario, Canada
| | - Magali Pham
- Department of Radiology, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Daniel Wong
- Department of Cardiac Surgery, Royal Columbian Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Whitlock
- Department of Cardiac Surgery, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael W A Chu
- Department of Cardiac Surgery, London Health Science Center, Western University, London, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada; Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY.
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Stelzer PE. Invited Commentary. Ann Thorac Surg 2019; 109:1131-1132. [PMID: 31604090 DOI: 10.1016/j.athoracsur.2019.08.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/17/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Paul E Stelzer
- Department of Cardiovascular Surgery GP2W, Mount Sinai Medical Center, 1190 Fifth Ave, New York, NY 10029-6574.
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11
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Pulmonary Valve Function Late After Ross Procedure in 443 Adult Patients. Ann Thorac Surg 2019; 109:1127-1131. [PMID: 31518586 DOI: 10.1016/j.athoracsur.2019.07.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/04/2019] [Accepted: 07/16/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Limited data exist on long-term pulmonary valve function after the Ross procedure. This study sought to determine the long-term function of the pulmonary valve in 443 consecutive adult patients who underwent a Ross procedure. METHODS All 443 patients who underwent a Ross procedure between November 1992 and March 2018 were reviewed retrospectively. All underwent pulmonary valve replacement using a cryopreserved pulmonary allograft. Freedom from the study's outcomes were calculated using Kaplan Meier survival. Risk factors for valve failure were analyzed using Cox regression. RESULTS Mean age at time of operation was 39 years (range: 15-66 years). There was 1 (0.2%, 1 of 443) operative mortality. Nine patients required reintervention on the pulmonary allograft at a mean 6.1 years (range: 1-12 years) after Ross procedure. Patients required pulmonary allograft reintervention for infective endocarditis (n = 4), severe pulmonary stenosis (n = 4), or severe pulmonary regurgitation (n = 1). Freedom from pulmonary allograft reintervention was 98.9% (95% confidence interval [CI] 97.1%-99.6%), 97.7% (95% CI 95.1%-98.9%), 96.6% (95% CI 93.3%-98.3%), and 96.6% (95% CI 93.3%-98.3%) at 5, 10, 15, and 20 years, respectively. Freedom from pulmonary allograft dysfunction (at least moderate pulmonary regurgitation and/or mean systolic gradient ≥ 25 mm Hg and/or reintervention) was 94.5% (95% CI 91.6%-96.4%), 88.1% (95% CI 83.6%-91.4%), 84.9% (95% CI 79.6%-88.9%), and 78.3% (95% CI 69.5%-84.9%) at 5, 10, 15, and 20 years, respectively. No risk factors were identified to influence pulmonary valve durability. CONCLUSIONS The pulmonary valve allograft gives excellent long-term function when used in adults undergoing the Ross procedure. Reintervention on the pulmonary valve is rare and significant pulmonary allograft dysfunction is uncommon.
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12
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Poh CL, Buratto E, Larobina M, Wynne R, O'Keefe M, Goldblatt J, Tatoulis J, Skillington PD. The Ross procedure in adults presenting with bicuspid aortic valve and pure aortic regurgitation: 85% freedom from reoperation at 20 years. Eur J Cardiothorac Surg 2019; 54:420-426. [PMID: 29546380 DOI: 10.1093/ejcts/ezy073] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/01/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The Ross procedure has demonstrated excellent results when performed in patients with aortic stenosis or mixed aortic valve disease [aortic stenosis and aortic regurgitation (AR)]. However, due to its reported risk of late reoperation, it is not recommended under current guidelines for patients presenting with bicuspid aortic valve and pure AR. We have analysed our own results in light of this recommendation. METHODS Between 1993 and 2016, 129 consecutive patients with a mean age of 34.7 ± 10.6 years (range 16-64 years) presented with bicuspid aortic valve and pure AR and underwent the Ross procedure. Patients were reviewed annually and had 2nd yearly transthoracic echocardiograms during follow-up. The unit had a liberal reoperation policy where reoperation was performed if patients developed recurrent moderate or greater AR during follow-up. RESULTS There was 1 inpatient death, and 3 late deaths over a mean follow-up duration of 9.6 ± 6.8 years. Late survival at 10 and 20 years post-surgery were 99% [95% confidence interval (CI) 94-100] and 95% (95% CI 85-99), respectively. Eleven patients underwent redo aortic valve replacement (AVR) and 4 patients had redo pulmonary valve replacement. Freedom from reoperation for AVR and more-than-mild AR at 10 and 20 years post-surgery were 89% (95% CI 81-94) and 85% (95% CI 74-92), respectively. Having longer aortic cross-clamp (hazard ratio 1.03, 95% CI 1.00-1.06; P = 0.05) and cardiopulmonary bypass times (hazard ratio 1.02, 95% CI 1.00-1.05; P = 0.05), and having a larger preoperative sinotubular junction diameter (hazard ratio 1.15, 95% CI 1.03-1.30; P = 0.02) were significant predictors of having redo AVR or significant AR at follow-up. CONCLUSIONS With a 20-year freedom from redo AVR and greater-than-mild residual AR of 85%, the utilization of the Ross procedure in bicuspid aortic valve patients with pure AR should be considered.
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Affiliation(s)
- Chin L Poh
- Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Edward Buratto
- Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - Marco Larobina
- Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Rochelle Wynne
- Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,School of Nursing & Midwifery, Deakin University, Geelong, VIC, Australia
| | - Michael O'Keefe
- Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - John Goldblatt
- Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - James Tatoulis
- Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - Peter D Skillington
- Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
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D'Alto M, Budts W, Diller GP, Mulder B, Egidy Assenza G, Oreto L, Ciliberti P, Bassareo PP, Gatzoulis MA, Dimopoulos K. Does gender affect the prognosis and risk of complications in patients with congenital heart disease in the modern era? Int J Cardiol 2019; 290:156-161. [PMID: 31085083 DOI: 10.1016/j.ijcard.2019.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/26/2019] [Accepted: 05/03/2019] [Indexed: 11/17/2022]
Abstract
Gender differences in the outcome of acquired cardiovascular disease are well known, but available literature on the influence of gender in congenital heart disease (CHD) is limited. Registries have provided valuable, albeit at times conflicting data. Higher mortality rates have been reported in older males with CHD, while sudden cardiac death is more prevalent in young males. However, mortality around surgery for CHD is higher in girls compared to boys, likely due to smaller body size. Women are at higher risk of developing pulmonary arterial hypertension, but at lower risk of adverse aortic outcomes, even though they are less likely to receive aortic surgery. Finally, women have a lower risk of presenting with infective endocarditis compared to men. The underlying reasons for gender differences in CHD can be attributed to genetic, hormonal, behavioural and other causes. The aim of the present paper is to provide an overview of available evidence on gender differences in CHD and their impact on outcome.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Second University of Naples - Monaldi Hospital, Naples, Italy.
| | - Werner Budts
- Division of Cardiovascular Diseases, University Hospitals Leuven - Department of Cardiovascular Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Gerhard P Diller
- Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University of Münster, Münster, Germany
| | - Barbara Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Gabriele Egidy Assenza
- Pediatric Cardiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Lilia Oreto
- Department of Paediatrics, University of Messina, Messina, Italy
| | - Paolo Ciliberti
- Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Pier Paolo Bassareo
- University College of Dublin, Mater Misericordiae University Teaching Hospital, Dublin, Ireland
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
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Etnel JR, Grashuis P, Huygens SA, Pekbay B, Papageorgiou G, Helbing WA, Roos-Hesselink JW, Bogers AJ, Mokhles MM, Takkenberg JJ. The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation. Circ Cardiovasc Qual Outcomes 2018; 11:e004748. [DOI: 10.1161/circoutcomes.118.004748] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jonathan R.G. Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Pepijn Grashuis
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Simone A. Huygens
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
- Erasmus School of Health Policy & Management, ErasmusUniversity Rotterdam, The Netherlands (S.A.H.)
| | - Begüm Pekbay
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Grigorios Papageorgiou
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands (G.P.)
| | - Willem A. Helbing
- Division of Cardiology, Department of Pediatrics, Erasmus University Medical Center, Sophia Children’s Hospital, Rotterdam, The Netherlands (W.A.H.)
| | - Jolien W. Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (J.W.R.-H.)
| | - Ad J.J.C. Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - M. Mostafa Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Johanna J.M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
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Oeser C, Uyanik-Uenal K, Kocher A, Laufer G, Andreas M. Long-term performance of pulmonary homografts after the Ross procedure: experience up to 25 years. Eur J Cardiothorac Surg 2018; 55:876-884. [DOI: 10.1093/ejcts/ezy372] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/24/2018] [Accepted: 10/04/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Claudia Oeser
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Alfred Kocher
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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16
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da Costa FD, Etnel JR, Charitos EI, Sievers HH, Stierle U, Fornazari D, Takkenberg JJ, Bogers AJ, Mokhles MM. Decellularized Versus Standard Pulmonary Allografts in the Ross Procedure: Propensity-Matched Analysis. Ann Thorac Surg 2018; 105:1205-1213. [DOI: 10.1016/j.athoracsur.2017.09.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/03/2017] [Accepted: 09/27/2017] [Indexed: 11/26/2022]
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Sharabiani MTA, Dorobantu DM, Mahani AS, Turner M, Peter Tometzki AJ, Angelini GD, Parry AJ, Caputo M, Stoica SC. Aortic Valve Replacement and the Ross Operation in Children and Young Adults. J Am Coll Cardiol 2017; 67:2858-70. [PMID: 27311525 DOI: 10.1016/j.jacc.2016.04.021] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/29/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND There are several options available for aortic valve replacement (AVR), with few comparative reports in the literature. The optimal choice for AVR in each age group is not clear. OBJECTIVES The study sought to report and compare outcomes after AVR in the young using data from a national database. METHODS AVR procedures were compared after advanced matching, both in pairs and in a 3-way manner, using a Bayesian dynamic survival model. RESULTS A total of 1,501 patients who underwent AVR in the United Kingdom between 2000 and 2012 were included. Of these, 47.8% had a Ross procedure, 37.8% a mechanical AVR, 10.9% a bioprosthesis AVR, and 3.5% a homograft AVR, with Ross patients being significantly younger when compared to the other groups. Overall survival at 12 years was 94.6%. In children, the Ross procedure had a 12.7% higher event-free probability (death or any reintervention) at 10 years when compared to mechanical AVR (p = 0.05). We also compared all procedures except the homograft in a matched population of young adults, where the bioprosthesis had the lowest event-free probability of 78.8%, followed by comparable results in mechanical AVR and Ross, with 86.3% and 89.6%, respectively. Younger age was associated with mortality and pulmonary reintervention in the Ross group and with aortic reintervention in the mechanical AVR. Of all 3 options, only the patients undergoing the Ross procedure approached the survival of the general population. CONCLUSIONS AVR in the young achieves good results, with the Ross being overall better suited for this age group, especially in children. Although freedom from aortic valve reintervention is superior after the Ross procedure, the need for homograft reinterventions is an issue to take into account. All methods have advantages and limitations, with reinterventions being an issue in the long term for all, more crucially in smaller children.
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Affiliation(s)
| | - Dan M Dorobantu
- Department of Cardiothoracic Surgery, University Hospitals Bristol NHS Trust, Bristol, United Kingdom; Cardiology Department, "Prof. C.C. Iliescu" Emergency Institute for Cardiovascular Diseases, Bucharest, Romania.
| | | | - Mark Turner
- Department of Cardiothoracic Surgery, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Andrew J Peter Tometzki
- Department of Cardiothoracic Surgery, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Gianni D Angelini
- Department of Cardiothoracic Surgery, Imperial College, London, United Kingdom; Department of Cardiothoracic Surgery, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Andrew J Parry
- Department of Cardiothoracic Surgery, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Massimo Caputo
- Department of Cardiothoracic Surgery, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Serban C Stoica
- Department of Cardiothoracic Surgery, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
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18
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Pulmonary homograft stenosis in the Ross procedure: Incidence, clinical impact and predictors in long-term follow-up. Arch Cardiovasc Dis 2017; 110:214-222. [PMID: 28043783 DOI: 10.1016/j.acvd.2016.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Ross procedure is used in the treatment of selected patients with aortic valve disease. Pulmonary graft stenosis can appear in the long-term follow-up after the Ross intervention, but the factors involved and its clinical implications are not fully known. AIM To describe the incidence, clinical impact and predictors of homograft stenosis and reintervention after the Ross procedure in a prospective series in a tertiary referral hospital. METHODS From 1997 to 2009, 107 patients underwent the Ross procedure (mean age: 30±11 years; 69% men; 21 aged<18 years), and were followed for echocardiographic homograft stenosis (peak gradient>36mmHg) and surgical or percutaneous homograft reintervention. RESULTS After 15 years of follow-up (median: 11 years), echocardiographic and clinical data were available in 91 (85%) and 104 (98%) patients, respectively: 26/91 (29%) patients developed homograft stenosis; 10/104 (10%) patients underwent 13 homograft reintervention procedures (three patients underwent surgical replacement, three received a percutaneous pulmonary valve and one needed stent implantation). The other three patients underwent two consecutive procedures in follow-up; one died because of a procedure-related myocardial infarction. Rates of survival free from homograft stenosis and reintervention at 1, 5 and 10 years were 96%, 82% and 75% and 99%, 94% and 91%, respectively. Paediatric patients had worse survival free from homograft stenosis (hazard ratio [HR] 3.50, 95% confidence interval [CI]: 1.56-7.90; P=0.002), although there were no significant differences regarding reintervention (HR: 2.01, 95% CI: 0.52-7.78; P=0.31). Younger age of homograft donor was also a stenosis predictor (HR: 0.97, 95% CI: 0.94-0.99; P=0.046). CONCLUSIONS The probabilities of homograft stenosis and reintervention 10 years after the Ross procedure were 29% and 10%, respectively; only one patient had a reintervention-related death. Younger donor and recipient age were associated with a higher rate of stenosis.
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19
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Right Ventricular Outflow Tract Replacement With Xenografts in Ross Patients Older Than 60 Years. Ann Thorac Surg 2016; 101:2252-9. [DOI: 10.1016/j.athoracsur.2015.12.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2015] [Indexed: 11/24/2022]
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20
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Skoglund K, Eriksson P, Svensson G, Dellborg M. Homograft reconstruction of the right ventricular outflow tract in adults with congenital heart disease: a systematic review. Interact Cardiovasc Thorac Surg 2015; 22:57-62. [DOI: 10.1093/icvts/ivv264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/20/2015] [Indexed: 11/14/2022] Open
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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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