1
|
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.
Collapse
|
2
|
Biomechanics of Pulmonary Autograft as Living Tissue: A Systematic Review. Bioengineering (Basel) 2022; 9:bioengineering9090456. [PMID: 36135002 PMCID: PMC9495771 DOI: 10.3390/bioengineering9090456] [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: 07/27/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: The choice of valve substitute for aortic valve surgery is tailored to the patient with specific indications and contraindications to consider. The use of an autologous pulmonary artery (PA) with a simultaneous homograft in the pulmonary position is called a Ross procedure. It permits somatic growth and the avoidance of lifelong anticoagulation. Concerns remain on the functionality of a pulmonary autograft in the aortic position when exposed to systemic pressure. Methods: A literature review was performed incorporating the following databases: Pub Med (1996 to present), Ovid Medline (1958 to present), and Ovid Embase (1982 to present), which was run on 1 January 2022 with the following targeted words: biomechanics of pulmonary autograft, biomechanics of Ross operation, aortic valve replacement and pulmonary autograph, aortic valve replacement and Ross procedure. To address the issues with heterogeneity, studies involving the pediatric cohort were also analyzed separately. The outcomes measured were early- and late-graft failure alongside mortality. Results: a total of 8468 patients were included based on 40 studies (7796 in pediatric cohort and young adult series and 672 in pediatric series). There was considerable experience accumulated by various institutions around the world. Late rates of biomechanical failure and mortality were low and comparable to the general population. The biomechanical properties of the PA were superior to other valve substitutes. Mathematical and finite element analysis studies have shown the potential stress-shielding effects of the PA root. Conclusion: The Ross procedure has excellent durability and longevity in clinical and biomechanical studies. The use of external reinforcements such as semi-resorbable scaffolds may further extend their longevity.
Collapse
|
3
|
Nappi F, Iervolino A, Avtaar Singh SS. The effectiveness and safety of pulmonary autograft as living tissue in Ross procedure: a systematic review. Transl Pediatr 2022; 11:280-297. [PMID: 35282027 PMCID: PMC8905099 DOI: 10.21037/tp-21-351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Reports on effectiveness and safety after the implant of pulmonary autograft (PA) living tissue in Ross procedure, to treat both congenital and acquired disease of the aortic valve and left ventricular outflow tract (LVOT), show variable durability results. We undertake a quantitative systematic review of evidence on outcome after the Ross procedure with the aim to improve insight into outcome and potential determinants. METHODS A systematic search of reports published from October 1979 to January 2021 was conducted (PubMed, Ovid Medline, Ovid Embase and Cochrane library) reporting outcomes after the Ross procedure in patients with diseased aortic valve with or without LVOT. Inclusion criteria were observational studies reporting on mortality and/or morbidity after autograft aortic valve or root replacement, completeness of follow-up >90%, and study size n≥30. Forty articles meeting the inclusion criteria were allocated to two categories: pediatric patient series and young adult patient series. Results were tabulated for a clearer presentation. RESULTS A total of 342 studies were evaluated of which forty studies were included in the final analysis as per the eligibility criteria. A total of 8,468 patients were included (7,796 in pediatric cohort and young adult series and 672 in pediatric series). Late mortality rates were remarkably low alongside similar age-matched mortality with the general population in young adults. There were differences in implantation techniques as regard the variability in stress and the somatic growth that recorded conflicting outcomes regarding the miniroot vs the subcoronary approach. DISCUSSION The adaptability of lung autograft to allow for both stress variability and somatic growth make it an ideal conduit for Ross's operation. The use of the miniroot technique over subcoronary implantation for better adaptability to withstand varying degrees of stress is perhaps more applicable to different patient subgroups.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | | | | |
Collapse
|
4
|
Yacoub MH, Tsang V, Sarathchandra P, Jensen H, Hughes S, Latif N. Long-term adaptive versus maladaptive remodelling of the pulmonary autograft after the Ross operation. Eur J Cardiothorac Surg 2021; 57:977-985. [PMID: 32129834 DOI: 10.1093/ejcts/ezaa019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Following the Ross operation, the pulmonary autograft undergoes structural changes (remodelling). We sought to determine the extent, nature and possible determinants of long-term remodelling in the different components of the pulmonary autograft. METHODS Ten pulmonary autografts and 12 normal control valves (6 pulmonary and 6 aortic) were examined by conventional histology, immunocytochemistry and electron microscopy. The structural changes were quantified by morphometry. RESULTS The leaflets from free-standing root replacement valves demonstrated thickening to levels comparable to the normal aortic leaflets, largely due to the addition of a thin layer of 'neointima' formed of radial elastic fibres, collagen bundles and glycoaminoglycans, on the ventricular aspect of the leaflets. The leaflets of valves from sub-coronary implantation demonstrated a significantly thicker fibroelastic layer on the ventricularis and calcium deposition in the fibrosa. The media of the explanted valves showed increased number of lamellar units to levels comparable to normal aortic roots. Electron microscopy of valves inserted as free-standing roots showed increased organization into continuous layers. However, intralamellar components showed varying degrees of 'disorganization' in comparison to those in the normal aortic media. In addition, there was a marked increase in the number of vasa vasorum with thickened arteriolar wall in the outer media and adventitia. CONCLUSIONS Following the Ross operation, in the very long term, all components of the autograft showed varying degrees of remodelling, which was judged to be largely adaptive. Defining the type, determinants and possible functional effects of remodelling could help in understanding and optimizing the results of the Ross operation.
Collapse
Affiliation(s)
- Magdi H Yacoub
- Department of Tissue Engineering, Imperial College London and Heart Science Centre, Harefield, Middlesex, UK
| | - Victor Tsang
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Padmini Sarathchandra
- Department of Tissue Engineering, Imperial College London and Heart Science Centre, Harefield, Middlesex, UK
| | - Hanna Jensen
- Department of Pathology, University College London, London, UK
| | - Sian Hughes
- Department of Pathology, University College London, London, UK
| | - Najma Latif
- Department of Tissue Engineering, Imperial College London and Heart Science Centre, Harefield, Middlesex, UK
| |
Collapse
|
5
|
Murin P, Weixler VHM, Moulla-Zeghouane J, Romanchenko O, Schleiger A, Lorenzen V, Sinzobahamvya N, Zacek P, Photiadis J, Cho MY. Subcoronary Ross/Ross-Konno operation in children and young adults: initial single-centre experience. Eur J Cardiothorac Surg 2021; 59:226-233. [PMID: 33141218 DOI: 10.1093/ejcts/ezaa307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/19/2020] [Accepted: 07/18/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES We sought to evaluate the outcome after modified subcoronary Ross/Ross-Konno operation in children and young adults. METHODS Between January 2013 and January 2019, a total of 50 patients with median age of 6.3 years (range 0.02-36.5 years, 58% males), including 10 infants (20%), received modified subcoronary Ross/Ross-Konno operation at our institution. Survival, morbidity, reinterventions, aortic valve function and aortic root dimensions were analysed. RESULTS At a median follow-up of 31.2 months (range 14.4-51 months), there were 1 early death and 1 late death, both in the infant group. The overall survival at 5 years after the operation was 95%. Two patients needed aortic valve replacement, 11 and 15 months after their Ross operation. At 5 years, freedoms from reoperation on the autograft and on the right ventricle to pulmonary artery conduit were 94% and 97%, respectively. Freedom from aortic valve regurgitation greater than mild was 97% at 5 years. Median dimensions of the aortic root at all levels remained in normal range at last visit. Forty-four patients (95%) were in New York Heart Association class I with normal left ventricular function. CONCLUSIONS The initial experience with the subcoronary Ross/Ross-Konno operation in children and young adults showed excellent outcome. The mortality and morbidity among infants remain significant. The described technique is reproducible and might be advantageous in situations when prosthetic supporting techniques interfere with somatic growth.
Collapse
Affiliation(s)
- Peter Murin
- Department of Congenital Heart Surgery - Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Viktoria H M Weixler
- Department of Congenital Heart Surgery - Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Jasmin Moulla-Zeghouane
- Department of Congenital Heart Surgery - Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Olga Romanchenko
- Department of Congenital Heart Surgery - Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease - Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Victoria Lorenzen
- Department of Congenital Heart Disease - Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Nicodème Sinzobahamvya
- Department of Congenital Heart Surgery - Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Pavel Zacek
- Department of Cardiac Surgery, Faculty of Medicine, Charles University Hospital in Prague, Hradec Kralove, Czech Republic
| | - Joachim Photiadis
- Department of Congenital Heart Surgery - Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery - Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| |
Collapse
|
6
|
Chiarini A, Dal Prà I, Faggian G, Armato U, Luciani GB. Maladaptive remodeling of pulmonary artery root autografts after Ross procedure: A proteomic study. J Thorac Cardiovasc Surg 2020; 159:621-632.e3. [DOI: 10.1016/j.jtcvs.2019.07.083] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/26/2019] [Accepted: 07/02/2019] [Indexed: 12/15/2022]
|
7
|
Nappi F, Nenna A, Larobina D, Carotenuto AR, Jarraya M, Spadaccio C, Fraldi M, Chello M, Acar C, Carrel T. Simulating the ideal geometrical and biomechanical parameters of the pulmonary autograft to prevent failure in the Ross operation. Interact Cardiovasc Thorac Surg 2019. [PMID: 29538653 DOI: 10.1093/icvts/ivy070] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Reinforcements for the pulmonary autograft (PA) in the Ross operation have been introduced to avoid the drawback of conduit expansion and failure. With the aid of an in silico simulation, the biomechanical boundaries applied to a healthy PA during the operation were studied to tailor the best implant technique to prevent reoperation. METHODS Follow-up echocardiograms of 66 Ross procedures were reviewed. Changes in the dimensions and geometry of reinforced and non-reinforced PAs were evaluated. Miniroot and subcoronary implantation techniques were used in this series. Mechanical stress tests were performed on 36 human pulmonary and aortic roots explanted from donor hearts. Finite element analysis was applied to obtain high-fidelity simulation under static and dynamic conditions of the biomechanical properties and applied stresses on the PA root and leaflet and the similar components of the native aorta. RESULTS The non-reinforced group showed increases in the percentages of the mean diameter that were significantly higher than those in the reinforced group at the level of the Valsalva sinuses (3.9%) and the annulus (12.1%). The mechanical simulation confirmed geometrical and dimensional changes detected by clinical imaging and demonstrated the non-linear biomechanical behaviour of the PA anastomosed to the aorta, a stiffer behaviour of the aortic root in relation to the PA and similar qualitative and quantitative behaviours of leaflets of the 2 tissues. The annulus was the most significant constraint to dilation and affected the distribution of stress and strain within the entire complex, with particular strain on the sutured regions. The PA was able to evenly absorb mechanical stresses but was less adaptable to circumferential stresses, potentially explaining its known dilatation tendency over time. CONCLUSIONS The absence of reinforcement leads to a more marked increase in the diameter of the PA. Preservation of the native geometry of the PA root is crucial; the miniroot technique with external reinforcement is the most suitable strategy in this context.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Domenico Larobina
- Institute for Polymers, Composites and Biomaterials, National Research Council of Italy, Rome, Italy
| | - Angelo Rosario Carotenuto
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, Università di Napoli 'Federico II', Naples, Italy
| | | | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Massimiliano Fraldi
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, Università di Napoli 'Federico II', Naples, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Christophe Acar
- Banc de Tissus Humains Hopital Saint Louis, Paris, France.,Department of Cardiac Surgery, Hopital La Pitie Salpetriere, Paris, France
| | - Thierry Carrel
- Deptartment of cardiovascular surgery, University Hospital of Bern, Bern, Switzerland
| |
Collapse
|
8
|
Ando Y, Ochiai Y, Tokunaga S, Hisahara M, Baba H, Miyagi C, Takigawa T. Size and Stiffness of the Pulmonary Autograft after the Ross Procedure in Children. Pediatr Cardiol 2019; 40:776-783. [PMID: 30734094 DOI: 10.1007/s00246-019-02064-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/29/2019] [Indexed: 11/24/2022]
Abstract
Progressive dilatation of the pulmonary autograft is one of the greatest concerns after the Ross procedure. Increased stress in the arterial wall may cause changes in the elastic properties of the pulmonary autograft, and thus lead to pathological dilatation. The present study aimed to investigate the changes in the autograft diameter and stiffness during follow-up after the Ross procedure. A total of ten patients underwent the Ross procedure at our institution between 2003 and 2011. Echocardiography was used to measure the diameters of the pulmonary autograft at the level of the annulus, sinus of Valsalva, and sinotubular junction. The stiffness index was calculated from the angiographic data, and compared with that of 16 age-matched control children. The diameters of the pulmonary autograft increased throughout the follow-up period, particularly at the level of the sinus of Valsalva and at the sinotubular junction. The aortic root was stiffer in Ross patients compared with control children (7.9 ± 1.8 vs. 3.9 ± 0.7 immediately postoperatively, p < 0.01; 10.1 ± 2.8 vs. 4.2 ± 1.4 at 5 years postoperatively, p < 0.01). Although no significant relationship was found between the stiffness index and the autograft diameter, the stiffness index tended to increase over time. Dilatation of the pulmonary autograft was accompanied by progressive change in aortic stiffness. Longer follow-up is warranted to clarify the impact of this change in aortic stiffness on autograft failure.
Collapse
Affiliation(s)
- Yusuke Ando
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan.
| | - Yoshie Ochiai
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Shigehiko Tokunaga
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Manabu Hisahara
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Hironori Baba
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Chihiro Miyagi
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| | - Tomoya Takigawa
- Department of Cardiovascular Surgery, Japan Community Health Care Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, 806-8501, Japan
| |
Collapse
|
9
|
Valve performance classification in 630 subcoronary Ross patients over 22 years. J Thorac Cardiovasc Surg 2018; 156:79-86.e2. [PMID: 29606322 DOI: 10.1016/j.jtcvs.2018.03.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/30/2018] [Accepted: 03/05/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To define the function of the "Ross valves" and its clinical meaning in a practical valve performance classification as part of the outcome analysis. METHODS From 1994 to 2017, 630 consecutive patients underwent the subcoronary Ross procedure at our institution. The valve performance classification combines hemodynamics, symptoms, and management criteria. Median follow-up was 12.5 years (maximum 22.3 years, 7404 patient-years, 99.4% completeness). RESULTS The mean age of the patients was 44.7 ± 11.9 years. Hospital deaths was 0.3% (n = 2). Twenty years after the operation survival was 73.1% (95% confidence interval [CI], 65.4%-81.6%) and statistically not different from the age- and gender-matched general population; freedom from reoperation was 85.9% (95% CI, 80.2%-92.0%; 0.6% per patient-year), 89.8% (95% CI, 84.3%-95.7%) for autograft, and 91.0% (95% CI, 86.3%-96.0%) for homograft. Preoperative annulus diameter, aortic regurgitation, annulus reinforcement, sinotubular junction reinforcement, and bicuspid aortic valve type were no significant risk factors for reoperation. At 20 years the probability of a patient being in valve performance class I to IV was 5%, 74%, 19%, and 1%, respectively. Time to reoperation was not different in bicuspid and tricuspid aortic valves; preoperative aortic stenosis tended to have better outcome of autograft function. CONCLUSIONS These up to 22 years data show that the subcoronary Ross procedure continues to provide an excellent tissue aortic valve replacement. The suggested valve performance classification emerged as a practical concept for outcome analysis with the probability of 79% being in the favorable class I or II at 20 years.
Collapse
|
10
|
Early and mid-term results of autograft rescue by Ross reversal: A one-valve disease need not become a two-valve disease. J Thorac Cardiovasc Surg 2018; 155:562-572. [DOI: 10.1016/j.jtcvs.2017.09.134] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/01/2017] [Accepted: 09/01/2017] [Indexed: 11/17/2022]
|
11
|
Sharma A, Cote AT, Hosking MCK, Harris KC. A Systematic Review of Infective Endocarditis in Patients With Bovine Jugular Vein Valves Compared With Other Valve Types. JACC Cardiovasc Interv 2017; 10:1449-1458. [PMID: 28728659 DOI: 10.1016/j.jcin.2017.04.025] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/11/2017] [Accepted: 04/19/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of this study was to systematically evaluate the incidence of infective endocarditis (IE) in right ventricle-to-pulmonary artery conduits and valves, comparing bovine jugular vein (BJV) valves with all others. BACKGROUND Recent evidence suggests that the incidence of IE is higher in patients with congenital heart disease who have undergone implantation of BJV valves in the pulmonary position compared with other valves. METHODS Systematic searches of published research were conducted using electronic databases (MEDLINE, Embase, and CINAHL) and citations cross-referenced current to April 2016. Included studies met the following criteria: patients had undergone right ventricle-to-pulmonary artery conduit or percutaneous pulmonary valve implantation, and investigators reported on the type of conduit or valve implanted, method of intervention (surgery or catheter based), IE incidence, and follow-up time. RESULTS Fifty studies (Levels of Evidence: 2 to 4) were identified involving 7,063 patients. The median cumulative incidence of IE was higher for BJV compared with other valves (5.4% vs. 1.2%; p < 0.0001) during a median follow-up period of 24.0 and 35.5 months, respectively (p = 0.03). For patients with BJV valves, the incidence of IE was not different between surgical and catheter-based valve implantation (p = 0.83). CONCLUSIONS There was a higher incidence of endocarditis with BJV valves than other types of right ventricle-to-pulmonary artery conduits. There was no difference in the incidence of endocarditis between catheter-based bovine valves and surgically implanted bovine valves, suggesting that the substrate for future infection is related to the tissue rather than the method of implantation.
Collapse
Affiliation(s)
- Ashutosh Sharma
- Children's Heart Centre, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Anita T Cote
- Children's Heart Centre, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; School of Human Kinetics, Trinity Western University, Langley, British Columbia, Canada; Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Martin C K Hosking
- Children's Heart Centre, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Kevin C Harris
- Children's Heart Centre, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.
| |
Collapse
|
12
|
Bouhout I, Ghoneim A, Poirier N, Cartier R, Demers P, Perrault LP, El-Hamamsy I. Impact of the Learning Curve on Early Outcomes Following the Ross Procedure. Can J Cardiol 2017; 33:493-500. [DOI: 10.1016/j.cjca.2016.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 10/27/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022] Open
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Kaza AK, Pigula FA. Are Bioprosthetic Valves Appropriate for Aortic Valve Replacement in Young Patients? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2016; 19:63-67. [PMID: 27060046 DOI: 10.1053/j.pcsu.2015.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/04/2015] [Accepted: 12/07/2015] [Indexed: 06/05/2023]
Abstract
Selection of a prosthetic aortic valve for use in the young patient is complicated by a variety of important considerations. Age, growth potential, activity and life style expectations, child bearing, and social factors, in addition to anatomic considerations, are all important to the recommendation of a prosthetic valve choice. We review the clinical experience and expectations of currently available prosthetic aortic valves available for the young patient, and describe the advantages and disadvantages for each.
Collapse
Affiliation(s)
- Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Frank A Pigula
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
15
|
Affiliation(s)
- Francesco Nappi
- Cardiac Surgery Center, Northern Cardiology Center Saint-Denis, Paris, France E-mail:
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hôpital de la Salpétrière, Paris, France
| |
Collapse
|
16
|
Tudorache I, Theodoridis K, Baraki H, Sarikouch S, Bara C, Meyer T, Höffler K, Hartung D, Hilfiker A, Haverich A, Cebotari S. Decellularized aortic allografts versus pulmonary autografts for aortic valve replacement in the growing sheep model: haemodynamic and morphological results at 20 months after implantation. Eur J Cardiothorac Surg 2015; 49:1228-38. [PMID: 26503725 DOI: 10.1093/ejcts/ezv362] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/26/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pulmonary autografts (PAs) represent the substitute of choice for aortic valve (AV) replacement, especially in children and young adults. Similarly, decellularized aortic valve allografts (DAVAs) have shown excellent mid-term function when implanted in the systemic circulation. The aim of this study was to compare the performance of DAVAs with that of pulmonary autografts after a Ross procedure in the growing sheep model. METHODS AV root replacement was performed in female lambs (25 ± 3.4 kg) using either DAVAs (n = 5) or pulmonary autografts (n = 5) as in the Ross procedure. Sheep undergoing the Ross procedure received a decellularized pulmonary allograft in place of pulmonary valve. Haemodynamics was investigated by echocardiography and magnetic resonance imaging. The roots were explanted at 20 months and examined by histology to determine the degree of repopulation and quality of the extracellular matrix, and by immunohistochemistry to characterize the repopulating cells. RESULTS The mean valve diameter increased from 16 to 21 and from 16 to 25 mm in DAVAs and PAs, respectively. At explantation, one PA and one DAVA exhibited moderate insufficiency. Significant differences in transvalvular gradient were only found in PAs between implantation and prior to explantation. The cusps of all implants were soft, pliable and showed no major signs of degeneration. In the decellularized allografts, cell repopulation occurred at the wall and cusp level with a well-maintained, three-layered cusp structure. Ventricular cusp surface of decellularized allografts was more strongly repopulated than the arterial surface. Cusps were covered with cells positive for endothelial markers and were also repopulated by interstitial cells. CONCLUSIONS DAVAs and PAs provide adequate haemodynamics after AV replacement in the growing sheep. While decellularized grafts are repopulated by endothelial and interstitial cells, autografts maintain in general their native cell distribution. Maintenance of valvular competence during enlargement of the valve ring is, in our opinion, representative of the capacity for physiological growth in both graft types.
Collapse
Affiliation(s)
- Igor Tudorache
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Karolina Theodoridis
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Hassina Baraki
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Bara
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tanja Meyer
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Klaus Höffler
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dagmar Hartung
- Department of Radiology, Hannover Medical School, Hannover, Germany
| | - Andres Hilfiker
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| |
Collapse
|
17
|
Nappi F, Spadaccio C, Fouret P, Hammoudi N, Chachques JC, Chello M, Acar C. An experimental model of the Ross operation: Development of resorbable reinforcements for pulmonary autografts. J Thorac Cardiovasc Surg 2015; 149:1134-42. [PMID: 25659190 DOI: 10.1016/j.jtcvs.2014.12.056] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 12/06/2014] [Accepted: 12/28/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To circumvent the issue of pulmonary autograft (PA) dilation after the Ross procedure, surgical reinforcement strategies have been suggested in clinical or anecdotal series. However, no preclinical large-animal model of the Ross procedure is available, which is needed to enable full comprehension of the pathologic mechanisms and the effectiveness of reinforcement techniques during growth. Our aim was to develop a large-animal model of the Ross operation, to reproduce the clinical scenario in which this procedure might be applied, and allow for development and testing of various devices and techniques to improve PA performance. In addition, we aimed to test the effectiveness of a bioresorbable mesh for PA reinforcement. METHODS An experimental model of transposition of the pulmonary trunk as an autograft in the aortic position has been developed and performed under cardiopulmonary bypass in 20 growing lambs, aged 3 months. The experimental design included: a control group that underwent PA transposition; a group in which the PA was reinforced with an external, synthetic, nonresorbable, polypropylene grid; and a group that received various combinations of resorbable meshes. Animals were followed up during growth for 6 months by angiography and echocardiography and eventually killed for pathologic analysis. RESULTS All animals survived the procedure with no complications. The model was easy and reproducible. Resorbable meshes prevented PA dilation and preserved its progressive growth process, aiding histologic remodelling. CONCLUSIONS We developed an easy and reproducible model of the Ross procedure, allowing for a reliable simulation of the clinical scenario. Resorbable PA reinforcement may represent an interesting option in this context.
Collapse
Affiliation(s)
- Francesco Nappi
- Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, Paris, France.
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Pierre Fouret
- Department of Pathology, Hôpital de la Salpétrière, Paris, France
| | - Nadjib Hammoudi
- Department of Cardiology, Hôpital de la Salpétrière, Paris, France
| | - Juan Carlos Chachques
- Laboratory of Biosurgical Research, Carpentier Foundation, Pompidou Hospital, University Paris Descartes, Paris, France
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hôpital de la Salpétrière, Paris, France
| |
Collapse
|
18
|
Sheikhzadeh S, De Backer J, Gorgan NR, Rybczynski M, Hillebrand M, Schüler H, Bernhardt AM, Koschyk D, Bannas P, Keyser B, Mortensen K, Radke RM, Mir TS, Kölbel T, Robinson PN, Schmidtke J, Berger J, Blankenberg S, von Kodolitsch Y. The main pulmonary artery in adults: a controlled multicenter study with assessment of echocardiographic reference values, and the frequency of dilatation and aneurysm in Marfan syndrome. Orphanet J Rare Dis 2014; 9:203. [PMID: 25491897 PMCID: PMC4272795 DOI: 10.1186/s13023-014-0203-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 11/26/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Echocardiographic upper normal limits of both main pulmonary artery (MPA) diameters (MPA-d) and ratio of MPA to aortic root diameter (MPA-r) are not defined in healthy adults. Accordingly, frequency of MPA dilatation based on echocardiography remains to be assessed in adults with Marfan syndrome (MFS). METHODS We enrolled 123 normal adults (72 men, 52 women aged 42 ± 14 years) and 98 patients with MFS (42 men, 56 women aged 39 ± 14 years) in a retrospective cross-sectional observational controlled study in four tertiary care centers. We defined outcome measures including upper normal limits of MPA-d and MPA-r as 95 quantile of normal persons, MPA dilatation as diameters > upper normal limits, MPA aneurysm as diameters >4 cm, and indication for surgery as MPA diameters >6 cm. RESULTS MPA diameters revealed normal distribution without correlation to age, sex, body weight, body height, body mass index and body surface area. The upper normal limit was 2.6 cm (95% confidence interval (CI) =2.44-2.76 cm) for MPA-d, and 1.05 (95% CI = .86-1.24) for MPA-r. MPA dilatation presented in 6 normal persons (4.9%) and in 68 MFS patients (69.4%; P < .001), MPA aneurysm presented only in MFS (15 patients; 15.3%; P < .001), and no patient required surgery. Mean MPA-r were increased in MFS (P < .001), but ratios >1.05 were equally frequent in 7 normal persons (5%) and in 8 MFS patients (10.5%; P = .161). MPA-r related to aortic root diameters (P = .042), reduced left ventricular ejection fraction (P = .006), and increased pulmonary artery systolic pressures (P = .040). No clinical manifestations of MFS and no FBN1 mutation characteristics related to MPA diameters. CONCLUSIONS We established 2.6 cm for MPA-d and 1.05 for MPA-r as upper normal limits. MFS exhibits a high prevalence of MPA dilatation and aneurysm. However, patients may require MPA surgery only in scarce circumstances, most likely because formation of marked MPA aneurysm may require LV dysfunction and increased PASP.
Collapse
Affiliation(s)
- Sara Sheikhzadeh
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Julie De Backer
- Centre for Medical Genetics, University Hospital Ghent, Ghent, Belgium.
| | - Neda Rahimian Gorgan
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Meike Rybczynski
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Mathias Hillebrand
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Helke Schüler
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Alexander M Bernhardt
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Dietmar Koschyk
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology, University Hospital Eppendorf, Hamburg, Germany.
| | - Britta Keyser
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany.
| | - Kai Mortensen
- Medizinische Klinik II / Kardiologie, Angiologie, am Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Germany.
| | - Robert M Radke
- Department für Kardiologie und Angiologie, Universitätsklinikum Münster, Münster, Germany.
| | - Thomas S Mir
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Tilo Kölbel
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Peter N Robinson
- Institute of Medical Genetics, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Jörg Schmidtke
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany.
| | - Jürgen Berger
- Department of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany.
| | - Stefan Blankenberg
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Yskert von Kodolitsch
- Centre of Cardiology and Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| |
Collapse
|
19
|
Twenty-Year Analysis of Autologous Support of the Pulmonary Autograft in the Ross Procedure. Ann Thorac Surg 2013; 96:823-9. [DOI: 10.1016/j.athoracsur.2013.04.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 04/06/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
|
20
|
Skillington PD, Mokhles MM, Wilson W, Grigg L, Larobina M, O'Keefe M, Takkenberg J. Inclusion cylinder method for aortic valve replacement utilising the Ross operation in adults with predominant aortic stenosis - 99% freedom from re-operation on the aortic valve at 15 years. Glob Cardiol Sci Pract 2013; 2013:383-94. [PMID: 24749112 PMCID: PMC3991211 DOI: 10.5339/gcsp.2013.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 12/07/2013] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND To report our experience with the Ross operation in patients with predominant aortic stenosis (AS) using an inclusion cylinder (IC) method. METHODS Out of 324 adults undergoing a Ross operation, 204 patients of mean age of 41.3 years (limits 16-62) underwent this procedure for either AS or mixed AS and regurgitation (AS/AR) between October, 1992 and February, 2012, implanting the PA with an IC method. Clinical follow up and serial echo data for this group is 97% complete with late mortality follow up 99% complete. RESULTS There has been zero (0%) early mortality, and late survival at 15 years is 98% (96%, 100%). Only one re-operation on the aortic valve for progressive aortic regurgitation (AR) has been required with freedom from re-operation on the aortic valve at 15 years being 99% (96%, 100%). The freedom from all re-operations on the aortic and pulmonary valves at 15 years is 97% (94%, 100%). Echo analysis at the most recent study shows that 98% have nil, trivial or mild AR. Aortic root size has remained stable, shown by long-term (15 year) echo follow up. CONCLUSIONS In an experience spanning 19 years, the Ross operation used for predominant AS using the IC method described, results in 99% freedom from re-operation on the aortic valve at 15 years, better than any other tissue or mechanical valve. For adults under 65 years without significant co-morbidities who present with predominant AS, the pulmonary autograft inserted with this technique gives excellent results.
Collapse
Affiliation(s)
| | - M Mostafa Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - William Wilson
- Department of Cardiology Royal Melbourne Hospital, Melbourne, Australia
| | - Leeanne Grigg
- Department of Cardiology Royal Melbourne Hospital, Melbourne, Australia
| | - Marco Larobina
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Australia
| | - Michael O'Keefe
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Australia
| | - Johanna Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
21
|
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]
|
22
|
Carrel T, Schönhoff F, Aymard T, Kadner A. Reinforcement of the Pulmonary Autograft with a Prosthetic Graft to Prevent Dilatation After the Ross Procedure. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.optechstcvs.2011.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
23
|
Luciani GB, Viscardi F, Puppini G, Faggian G, Mazzucco A. Aortic root physiology late after a "perfect" ross operation: magnetic resonance imaging study of three operative techniques. Artif Organs 2011; 35:1142-50. [PMID: 21517910 DOI: 10.1111/j.1525-1594.2011.01202.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In order to define physiological properties of the autograft root, magnetic resonance imaging (MRI) findings relative to three different operative techniques were compared with those of control subjects. Twenty-three patients, 18/5 M/F, aged 32 ± 9 years, underwent MRI assessment of the aortic root. Patients with normally functioning autograft valve and at least 4 years of follow-up (average 5.6 ± 1.9, range 4-10 years) were selected for each technique: six subcoronary (Group 1), nine inclusion (Group 2), and eight freestanding root (Group 3). Results were compared among patient groups and with seven control subjects, 6/1 M/F, aged 30 ± 2 years (P = ns). Morphological and functional properties were defined using transverse and paracoronal views, during systole and diastole. Mean aortic size in each group was greater than control, except for the LV-aortic junction and the sinus of Valsalva in Group 1 (26 ± 5 vs. 23 ± 3 mm, P = 0.2 and 33 ± 6 vs. 30 ± 5 mm, P = 0.3). Aortic valve plane rotation (P = 0.02) and root dilatation (P = 0.02) were more common in Group 3. Altered valve opening dynamics and asymmetrical aortic flow profile were also more common in Group 2 (P = 0.03) and Group 3 (P = 0.04). Distensibility was significantly reduced at sinus level in Group 2 and 3 compared with control (4.1 ± 3.5% and 3.6 ± 4.4% vs. 9.0 ± 4.7%, P = 0.03). Asymmetrical aortic flow profile was more common in patients with aortic dilatation (P = 0.05) and with severely reduced (<4%) root elasticity (P = 0.06). Among the three techniques, only subcoronary grafting allows preservation of physiological autograft valve dynamics, aortic flow and distensibility, at all root levels, late after operation. These findings may have relevant implications in the selection of the ideal Ross technique.
Collapse
|
24
|
El-Hamamsy I, Eryigit Z, Stevens LM, Sarang Z, George R, Clark L, Melina G, Takkenberg JJM, Yacoub MH. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 2010; 376:524-31. [PMID: 20684981 DOI: 10.1016/s0140-6736(10)60828-8] [Citation(s) in RCA: 251] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ideal substitute for aortic valve replacement in patients with aortic valve disease is not known. Our hypothesis was that the regulatory and adaptive properties of a living valve substitute could improve the long-term outcomes in patients. We therefore compared these outcomes after autograft aortic root replacement (Ross procedure) versus homograft aortic root replacement in adults. METHODS Male and female patients (<69 years) requiring aortic valve surgery were randomly assigned in a one-to-one ratio to receive an autograft or a homograft aortic root replacement in one centre in the UK. The random allocation sequence was computer generated. Treatment was not masked. The primary endpoint was survival of patients at 10 years after surgery. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN03530985. FINDINGS 228 patients were randomly assigned to receive an autograft or a homograft aortic root replacement. 12 patients were excluded because they were younger than 18 years; 108 in each group received the surgery they were assigned to and were analysed. There was one (<1%) perioperative death in the autograft group versus three (3%) in the homograft group (p=0.621). At 10 years, four patients died in the autograft group versus 15 in the homograft group. Actuarial survival at 10 years was 97% (SD 2) in the autograft group versus 83% (4) in the homograft group. Hazard ratio for death in the homograft group was 4.61 (95% CI 1.71-16.03; p=0.0060). Survival of patients in the autograft group was similar to that in an age-matched and sex-matched British population (96%). INTERPRETATION Our findings support the hypothesis that a living valve implanted in the aortic position can significantly improve the long-term outcomes in patients. FUNDING Funding Magdi Yacoub Institute.
Collapse
Affiliation(s)
- Ismail El-Hamamsy
- Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust, London, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Hörer J, Stierle U, Hanke T, Takkenberg J, Bogers A, Hemmer W, Rein J, Hübler M, Hetzer R, Sievers H, Lange R. Die Ross-Operation bei Kindern. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-010-0768-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
26
|
Hörer J, Hanke T, Stierle U, Takkenberg JJM, Bogers AJJC, Hemmer W, Rein JG, Hetzer R, Hübler M, Robinson DR, Sievers HH, Lange R. Neoaortic root diameters and aortic regurgitation in children after the Ross operation. Ann Thorac Surg 2009; 88:594-600; discussion 600. [PMID: 19632419 DOI: 10.1016/j.athoracsur.2009.04.077] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 04/20/2009] [Accepted: 04/22/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND For children who require aortic valve replacement, the Ross operation provides a unique advantage of growth potential of the pulmonary autograft in the aortic position. This study assessed the progression of autograft root diameters and its effect on aortic regurgitation (AR). METHODS Neoaortic echo dimensions from 48 children (<16 years) undergoing Ross operation who had follow-up echocardiograms before age 20 were analyzed (mean follow-up, 5.1 +/- 3.3 years). RESULTS The mean age at the time of the Ross operation was 10.0 +/- 4.3 years. Mean z values of the neoaortic annulus (1.5 +/- 0.4), sinus (2.5 +/- 0.4), and sinotubular junction (2.6 +/- 0.9) when the autograft was implanted were significantly larger compared with normal values (p < 0.001, all). The mean z values significantly increased with follow-up at the level of the sinus (0.5 +/- 0.1/year, p < 0.001) and the sinotubular junction (0.7 +/- 0.2, p < 0.001), but not at the level of the annulus (0.1 +/- 0.1, p = 0.59). AR increased with follow-up time (0.07 +/- 0.02 grade/year, p < 0.001). AR increased with sinotubular junction diameter (p = 0.028), but there was not significant evidence of an association with annulus diameter (p = 0.25) or sinus diameter (p = 0.40). CONCLUSIONS Children undergoing Ross operation have larger neoaortic root dimensions than healthy children. Growth of the annulus matches somatic growth. The diameters of the sinus and the sinotubular junction increase significantly relative to somatic growth. The latter may explain the development of AR.
Collapse
Affiliation(s)
- Jürgen Hörer
- Department of Cardiovascular Surgery, German Heart Center Munich at Technical University, Munich, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Hörer J, Hanke T, Stierle U, Takkenberg JJ, Bogers AJ, Hemmer W, Rein JG, Hetzer R, Hübler M, Robinson DR, Sievers HH, Lange R. Homograft Performance in Children After the Ross Operation. Ann Thorac Surg 2009; 88:609-15. [DOI: 10.1016/j.athoracsur.2009.04.100] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 04/22/2009] [Accepted: 04/24/2009] [Indexed: 11/15/2022]
|
28
|
Nordmeyer J, Lurz P, Tsang VT, Coats L, Walker F, Taylor AM, Khambadkone S, de Leval MR, Bonhoeffer P. Effective transcatheter valve implantation after pulmonary homograft failure: a new perspective on the Ross operation. J Thorac Cardiovasc Surg 2009; 138:84-8. [PMID: 19577061 PMCID: PMC2741608 DOI: 10.1016/j.jtcvs.2008.08.072] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 07/01/2008] [Accepted: 08/02/2008] [Indexed: 11/16/2022]
Abstract
Objective The Ross procedure offers good autograft function and low reoperation rates for the neoaortic valve; however, the rate of conduit dysfunction in the right ventricular outflow tract remains a concern. This study assessed percutaneous pulmonary valve implantation in this setting. Methods We retrospectively analyzed outcomes of 12 patients (mean age 28 ± 5 years) referred for percutaneous pulmonary valve implantation to treat right ventricle–pulmonary artery conduit failure 11.1 ± 3.3 years after Ross procedure. Results Percutaneous pulmonary valve implantation was feasible in all 12 patients, with no procedural complications (procedure time 99 ± 16 minutes, fluoroscopy time 21 ± 6 minutes). Right ventricular outflow tract gradient during catheterization and pulmonary regurgitant fraction on magnetic resonance imaging fell after valve implantation (gradient 34 ± 6 to 14 ± 3 mm Hg, P < .01, regurgitant fraction 20% ± 6% to 2% ± 1%, P < .05). After restoration of right ventricular outflow tract function, indexed right ventricular end-diastolic volume decreased (91 ± 13 to 78 ± 12 mL · beat−1 · m−2, P < .01) and maximal cardiopulmonary exercise performance improved (peak oxygen consumption 25.4 ± 2.3 to 30.8 ± 3.0 mL · kg−1 · min−1, P < .01). During follow-up (18.8 ± 4.6 months), there was 1 device explantation (restenosis). The probabilities of freedom from right ventricular outflow tract reoperation were 100% at 1 year and 90% at 3 years. Conclusions Percutaneous pulmonary valve implantation provides an effective transcatheter treatment strategy to prolong the lifespan of right ventricle–pulmonary artery conduits after the Ross procedure, reducing the reoperation burden on patients with aortic valve disease.
Collapse
Affiliation(s)
- Johannes Nordmeyer
- UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Böhm JO, Hemmer W, Rein JG, Horke A, Roser D, Blumenstock G, Botha CA. A Single-Institution Experience With the Ross Operation Over 11 Years. Ann Thorac Surg 2009; 87:514-20. [DOI: 10.1016/j.athoracsur.2008.10.093] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 10/30/2008] [Accepted: 10/30/2008] [Indexed: 11/16/2022]
|
30
|
Takkenberg JJ, Klieverik LM, Schoof PH, van Suylen RJ, van Herwerden LA, Zondervan PE, Roos-Hesselink JW, Eijkemans MJ, Yacoub MH, Bogers AJ. The Ross Procedure. Circulation 2009; 119:222-8. [DOI: 10.1161/circulationaha.107.726349] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Reports on outcome after the Ross procedure are limited by small study size and show variable durability results. A systematic review of evidence on outcome after the Ross procedure may improve insight into outcome and potential determinants.
Methods and Results—
A systematic review of reports published from January 2000 to January 2008 on outcome after the Ross procedure was undertaken. Thirty-nine articles meeting the inclusion criteria were allocated to 3 categories: (1) consecutive series, (2) adult patient series, and (3) pediatric patient series. With the use of an inverse variance approach, pooled morbidity and mortality rates were obtained. Pooled early mortality for consecutive, adult, and pediatric patients series was 3.0% (95% confidence interval [CI], 1.8 to 4.9), 3.2% (95% CI, 1.5 to 6.6), and 4.2% (95% CI, 1.4 to 11.5). Autograft deterioration rates were 1.15% (95% CI, 1.06 to 2.06), 0.78% (95% CI, 0.43 to 1.40), and 1.38%/patient-year (95% CI, 0.68 to 2.80), respectively, and for right ventricular outflow tract conduit were 0.91% (95% CI, 0.56 to 1.47), 0.55% (95% CI, 0.26 to 1.17), and 1.60%/patient-year (95% CI, 0.84 to 3.05), respectively. For studies with mean patient age >18 years versus mean patient age ≤18 years, pooled autograft and right ventricular outflow tract deterioration rates were 1.14% (95% CI, 0.83 to 1.57) versus 1.69% (95% CI, 1.02 to 2.79) and 0.65% (95% CI, 0.41 to 1.02) versus 1.66%/patient-year (95% CI, 0.98 to 2.82), respectively.
Conclusions—
The Ross procedure provides satisfactory results for both children and young adults. Durability limitations become apparent by the end of the first postoperative decade, in particular in younger patients.
Collapse
Affiliation(s)
- Johanna J.M. Takkenberg
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Loes M.A. Klieverik
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Paul H. Schoof
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Robert-Jan van Suylen
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Lex A. van Herwerden
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Pieter E. Zondervan
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Jolien W. Roos-Hesselink
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Marinus J.C. Eijkemans
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Magdi H. Yacoub
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| | - Ad J.J.C. Bogers
- From the Departments of Cardiothoracic Surgery (J.J.M.T., L.M.A.K., A.J.J.C.B.), Pathology (P.E.Z.), Cardiology (J.W.R.-H.), and Public Health (M.J.C.E.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (P.H.S.); Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands (R.J.v.S.); Department of Cardiothoracic Surgery, University Medical Center Utrecht,
| |
Collapse
|
31
|
de Kerchove L, Rubay J, Pasquet A, Poncelet A, Ovaert C, Pirotte M, Buche M, D'Hoore W, Noirhomme P, El Khoury G. Ross Operation in the Adult: Long-Term Outcomes After Root Replacement and Inclusion Techniques. Ann Thorac Surg 2009; 87:95-102. [DOI: 10.1016/j.athoracsur.2008.09.031] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 09/10/2008] [Accepted: 09/11/2008] [Indexed: 11/26/2022]
|
32
|
A single center's experience with the Ross procedure in pediatrics. Pediatr Cardiol 2008; 29:894-900. [PMID: 18401635 DOI: 10.1007/s00246-008-9224-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 01/18/2008] [Accepted: 03/22/2008] [Indexed: 10/22/2022]
Abstract
The use of a pulmonary autograft for aortic valve replacement (AVR) has become more prevalent than other forms of AVR in the pediatric population. We reviewed the data on pediatric patients who underwent the Ross procedure at our institution from 1993 to 2005. Sixty patients <18 years old who underwent a Ross procedure had available clinical and echocardiographic data collected and statistical analysis performed. Mortality rate was 3.3%, while overall survival and freedom from reoperation of either the homograft or the autograft were 96.7% and 66.2%, respectively, at 10 years. Freedom from reoperation of the left ventricular outflow tract was 60.5% at 10 years. Echocardiographic data showed aortic regurgitation to be mild or less in 76% of patients by last follow-up, while dilation of the sinuses of Valsalva had occurred in 52%. Compared to other AVR options, the Ross procedure in eligible pediatric patients demonstrates good intermediate survival rates and continued growth potential, yet a time-dependent need for reoperation.
Collapse
|
33
|
|
34
|
Surgical Management of Aortic Stenosis in a Child. Med J Armed Forces India 2008; 64:197-8. [PMID: 27408139 DOI: 10.1016/s0377-1237(08)80086-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2007] [Accepted: 03/10/2008] [Indexed: 11/23/2022] Open
|
35
|
Hanke T, Stierle U, Boehm JO, Botha CA, Matthias Bechtel JF, Erasmi A, Misfeld M, Hemmer W, Rein JG, Robinson DR, Lange R, Hörer J, Moritz A, Ozaslan F, Wahlers T, Franke UFW, Hetzer R, Hübler M, Ziemer G, Graf B, Ross DN, Sievers HH. Autograft regurgitation and aortic root dimensions after the Ross procedure: the German Ross Registry experience. Circulation 2007; 116:I251-8. [PMID: 17846313 DOI: 10.1161/circulationaha.106.678797] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Autograft regurgitation and root dilatation after the Ross procedure is of major concern. We reviewed data from the German Ross Registry to document the development of autograft regurgitation and root dilatation with time and also to compare 2 different techniques of autograft implantation. METHODS AND RESULTS Between 1990 and 2006 1014 patients (786 men, 228 women; mean age 41.2+/-15.3 years) underwent the Ross procedure using 2 different implantation techniques (subcoronary, n=521; root replacement, n=493). Clinical and serial echocardiographic follow up was performed preoperatively and thereafter annually (mean follow up 4.41+/-3.11 years, median 3.93 years, range 0 to 16.04 years; 5012 patient-years). For statistical analysis of serial echocardiograms, a hierarchical multilevel modeling technique was applied. Eight early and 28 late deaths were observed. Pulmonary autograft reoperations were required in 35 patients. Initial autograft regurgitation grade was 0.49 (root replacement 0.73, subcoronary 0.38) with an annual increase of grade 0.034 (root replacement 0.0259, subcoronary 0.0231). Annulus and sinus dimensions did not exhibit an essential increase over time in both techniques, whereas sinotubular junction diameter increased essentially by 0.5 mm per year in patients with root replacement. Patients with the subcoronary implantation technique showed nearly unchanged dimensions. Bicuspid aortic valve morphology did not have any consistent impact on root dimensions with time irrespective of the performed surgical technique. CONCLUSIONS The present Ross series from the German Ross Registry showed favorable clinical and hemodynamic results. Development of autograft regurgitation for both techniques was small and the annual progression thereof is currently not substantial. Use of the subcoronary technique and aortic root interventions with stabilizing measures in root replacement patients seem to prevent autograft regurgitation and dilatation of the aortic root within the timeframe studied.
Collapse
Affiliation(s)
- Thorsten Hanke
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Klieverik LMA, Takkenberg JJM, Bekkers JA, Roos-Hesselink JW, Witsenburg M, Bogers AJJC. The Ross operation: a Trojan horse?†. Eur Heart J 2007; 28:1993-2000. [PMID: 17303586 DOI: 10.1093/eurheartj/ehl550] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS The Ross operation is the operation of choice for children who require aortic valve replacement (AVR) and may also provide a good option in selected adult patients. Although the autograft does not require anticoagulation and has a superior haemodynamic profile, concern regarding autograft and allograft longevity has risen. In this light, we report the 13-year results of our prospective autograft cohort study. METHODS AND RESULTS Between 1988 and 2005, 146 consecutive patients underwent AVR with a pulmonary autograft at Erasmus Medical Center Rotterdam. Mean age was 22 years (SD 13; range 4 months-52 years), 66% were male. Hospital mortality was 2.7% (N = 4); during follow-up four more patients died. Thirteen-year survival was 94 +/- 2%. Over time, 22 patients required autograft reoperation for progressive neo-aortic root dilatation. In addition, eight patients required allograft reoperation. Freedom from autograft reoperation at 13 years was 69 +/- 7%. Freedom from allograft reoperation for structural failure at 13 years was 87 +/- 5%. Risk factors for autograft reoperation were previous AVR and adult patient age. CONCLUSION Although survival of the Rotterdam autograft cohort is excellent, over time a worrisome increase in reoperation rate is observed. Given the progressive autograft dilatation, careful follow-up of these patients is warranted in the second decade after operation.
Collapse
Affiliation(s)
- Loes M A Klieverik
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Bd 571, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|