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González LP, Ruiz-Ortiz M, Delgado M, Rodriguez S, Villalba R, Merino C, Casares J, Mesa D, de Lezo JS, Pan M. Letter to the Editor Ross procedure valve function, clinical outcomes and predictors after 25 years follow up. Curr Probl Cardiol 2024; 49:102534. [PMID: 38521294 DOI: 10.1016/j.cpcardiol.2024.102534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024]
Abstract
The following letter presents an answer of a comment of our work titled "Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up," recently published in your journal by Rangwala et al.1 As our colleagues point out, the Ross procedure has excellent survival rates but a significant risk of valve dysfunction and therefore reintervention at follow-up. Although the survival advantage with the Ross procedure appears to be consistent compared with mechanical valve substitutes, this benefit is not as clear compared with biological valve substitutes. However, biological valve substitutes also have significant reintervention rates during follow-up. The different surgical modifications of the Ross procedure have not clearly demonstrated better results in follow-up in terms of autograft reintervention. This procedure can be performed in a medium-volume center with good results as long as adequate patient selection and adequate surgical training are carried out.
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Affiliation(s)
| | - Martín Ruiz-Ortiz
- Department of Cardiology, Reina Sofia University Hospital, Córdoba, Spain; Maimónides Institute for Biomedical Research of Córdoba (IMIBIC), Córdoba, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain.
| | - Mónica Delgado
- Department of Cardiology, Reina Sofia University Hospital, Córdoba, Spain; Maimónides Institute for Biomedical Research of Córdoba (IMIBIC), Córdoba, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain
| | - Sara Rodriguez
- Department of Cardiology, Reina Sofia University Hospital, Córdoba, Spain
| | - Rafael Villalba
- Regional Blood Transfusion Centre and Tissue Bank, Córdoba, Spain
| | - Carlos Merino
- Department of Cardiovascular Surgery, Reina Sofia University Hospital, Córdoba, Spain
| | - Jaime Casares
- Department of Cardiovascular Surgery, Reina Sofia University Hospital, Córdoba, Spain
| | - Dolores Mesa
- Department of Cardiology, Reina Sofia University Hospital, Córdoba, Spain; Maimónides Institute for Biomedical Research of Córdoba (IMIBIC), Córdoba, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain
| | | | - Manuel Pan
- Department of Cardiology, Reina Sofia University Hospital, Córdoba, Spain; Maimónides Institute for Biomedical Research of Córdoba (IMIBIC), Córdoba, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Spain
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Rajab TK, Abdelrahman M, Schwartzenburg EJ, Aykut B, Turek JW, McVadon DH. Semilunar valve growth and function 10 years after infant heart transplantation: Predicting long-term outcomes of partial heart transplants. Pediatr Transplant 2024; 28:e14746. [PMID: 38566335 PMCID: PMC10997160 DOI: 10.1111/petr.14746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/06/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Partial heart transplants are a new type of pediatric transplant that replace defective heart valves with the parts of matched donor hearts containing the necessary valves. Short-term outcomes of partial heart transplants are excellent, but long-term outcomes are unknown. In order to predict the long-term outcomes of partial heart transplants, we evaluated long-term growth and function of semilunar heart valves transplanted in infancy as part of a heart transplant. METHODS All children who underwent infant heart transplantation at a single center from 1997 to 2014 were included in this study. Children in whom echocardiograms after heart transplantation and after 10 years were not available for review were excluded. The echocardiograms were reviewed by two authors to analyze semilunar valve annulus diameters, Z-scores, peak valve gradients, and valve regurgitation. Statistical difference was determined using two-tailed, paired sample t-tests with Bonferroni correction for multiple comparisons. RESULTS Data from 15 patients were analyzed. The aortic valve annulus averaged 1.3 cm (range 0.7-1.8 cm) immediately after transplantation and grew to an average of 1.7 cm (range 1.4-2.3 cm) after 10 years (p < .001). After 10 years, the aortic valve peak gradient avereraged 5.1 mmHg (range 2.1-15.5 mmHg) and none of the valves had more than trivial regurgitation. The pulmonary valve annulus averaged 1.5 cm (range 1.1-2.5 cm) immediately after transplantation and grew to an average of 2.1 cm (range 1.0-2.9 cm) after 10 years (p < .001). After 10 years, the pulmonary valve peak gradient averaged 4.3 mmHg (range 1.1-13.8 mmHg), and 7% of valves had moderate regurgitation. DISCUSSION Semilunar heart valves transplanted in infancy as part of a heart transplant demonstrate statistically significant growth and excellent function after 10 years. This predicts excellent long-term outcomes of partial heart transplants.
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Affiliation(s)
- Taufiek K Rajab
- Division of Pediatric Cardiovascular Surgery, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Mohamed Abdelrahman
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elridge J Schwartzenburg
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Berk Aykut
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph W Turek
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Deani H McVadon
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Myjavec A, Gofus J, Zacek P, Vobornik M, Shahin Y, Vojacek J. Technical considerations and sizing of external annuloplasty in the Ross procedure. Eur J Cardiothorac Surg 2024; 65:ezae118. [PMID: 38544298 DOI: 10.1093/ejcts/ezae118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/04/2024] [Accepted: 03/25/2024] [Indexed: 04/07/2024] Open
Abstract
Pure aortic regurgitation and dilation of aortic annulus are the most significant risk factors for the failure of pulmonary autograft after the Ross procedure. Aortic annuloplasty has a positive effect on the durability of the autograft. Previously, we described a technique for external annuloplasty with dedicated CORONEO ring. In the present manuscript, we suggest the sizing of annuloplasty based on the diameter of pulmonary autograft annulus.
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Affiliation(s)
- Andrej Myjavec
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Gofus
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Martin Vobornik
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Youssef Shahin
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
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Bouhout I, Singh S, Nguyen S, Vinogradsky A, Barrett C, Kalfa D, Bacha E, Goldstone A. Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure. J Thorac Cardiovasc Surg 2024; 167:1123-1131.e2. [PMID: 37385527 PMCID: PMC10751386 DOI: 10.1016/j.jtcvs.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Primary aortic insufficiency (AI) is a risk factor for autograft reintervention in adults undergoing the Ross procedure. We sought to examine the influence of preoperative AI on autograft durability in children and adolescents. METHODS From 1993 to 2020, 125 consecutive patients between ages 1 and 18 underwent a Ross procedure. The autograft was implanted using a full-root technique in 123 (98.4%) and included in a polyethelene terephthalate graft in 2 (1.6%). Patients with aortic stenosis (aortic stenosis group) (n = 85) were retrospectively compared with those with AI or mixed disease (AI group) (n = 40). Median length of follow-up was 8.2 years (interquartile range, 3.3-15.4 years). The primary end point was the incidence of severe AI or autograft reintervention. Secondary end points included changes in autograft dimensions analyzed using mixed-effect models. RESULTS The incidence of severe AI or autograft reintervention was 39.0% ± 13.0% in the AI group and 8.8% ± 4.4% in the aortic stenosis group at 15 years (P = .02). Annulus z scores increased in both aortic stenosis and AI groups over time (P < .001). However, the annulus dilated at a faster rate in the AI group (absolute difference, 3.8 ± 2.0 vs 2.5 ± 1.7; P = .03). Sinus of Valsalva z scores increased in both groups as well (P < .001), but at similar rates over time (P = .11). CONCLUSIONS Children and adolescents with AI undergoing the Ross procedure have higher rates of autograft failure. Patients with preoperative AI have more pronounced dilatation at the annulus. Akin to adults, a surgical aortic annulus stabilization technique that modulates growth is needed in children.
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Affiliation(s)
- Ismail Bouhout
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Sameer Singh
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Stephanie Nguyen
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Alice Vinogradsky
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Connor Barrett
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - David Kalfa
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Emile Bacha
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew Goldstone
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY.
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Bobylev D, Horke A, Avsar M, Cvitkovic T, Boethig D, Hazekamp M, Meyns B, Rega F, Dave H, Schmiady M, Ciubotaru A, Cheptanaru E, Vida V, Padalino M, Tsang V, Jashari R, Laufer G, Andreas M, Andreeva A, Tudorache I, Cebotari S, Haverich A, Sarikouch S. Matched comparison of decellularized homografts and bovine jugular vein conduits for pulmonary valve replacement in congenital heart disease. Cell Tissue Bank 2024; 25:55-66. [PMID: 36917328 PMCID: PMC10901942 DOI: 10.1007/s10561-023-10082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/23/2023] [Indexed: 03/16/2023]
Abstract
For decades, bovine jugular vein conduits (BJV) and classic cryopreserved homografts have been the two most widely used options for pulmonary valve replacement (PVR) in congenital heart disease. More recently, decellularized pulmonary homografts (DPH) have provided an alternative avenue for PVR. Matched comparison of patients who received DPH for PVR with patients who received bovine jugular vein conduits (BJV) considering patient age group, type of heart defect, and previous procedures. 319 DPH patients were matched to 319 BJV patients; the mean age of BJV patients was 15.3 (SD 9.5) years versus 19.1 (12.4) years in DPH patients (p = 0.001). The mean conduit diameter was 24.5 (3.5) mm for DPH and 20.3 (2.5) mm for BJV (p < 0.001). There was no difference in survival rates between the two groups after 10 years (97.0 vs. 98.1%, p = 0.45). The rate of freedom from endocarditis was significantly lower for BJV patients (87.1 vs. 96.5%, p = 0.006). Freedom from explantation was significantly lower for BJV at 10 years (81.7 vs. 95.5%, p = 0.001) as well as freedom from any significant degeneration at 10 years (39.6 vs. 65.4%, p < 0.001). 140 Patients, matched for age, heart defect type, prior procedures, and conduit sizes of 20-22 mm (± 2 mm), were compared separately; mean age BJV 8.7 (4.9) and DPH 9.5 (7.3) years (p = n.s.). DPH showed 20% higher freedom from explantation and degeneration in this subgroup (p = 0.232). Decellularized pulmonary homografts exhibit superior 10-year results to bovine jugular vein conduits in PVR.
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Affiliation(s)
- Dmitry Bobylev
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Horke
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tomislav Cvitkovic
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mark Hazekamp
- Department of Congenital Cardiac Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart Meyns
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hitendu Dave
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Martin Schmiady
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Anatol Ciubotaru
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Eduard Cheptanaru
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, Azienda Ospedaliera di Padova, University of Padua Medical School, Padua, Italy
| | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Azienda Ospedaliera di Padova, University of Padua Medical School, Padua, Italy
| | - Victor Tsang
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussels, Belgium
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Igor Tudorache
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany.
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Discussion to: Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure. J Thorac Cardiovasc Surg 2023; 167:1132-3. [PMID: 38142391 DOI: 10.1016/j.jtcvs.2023.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Indexed: 12/25/2023]
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Morgant MC, Bernard C, Lorgis L, Bouchot O. Transcatheter pulmonary valve replacement after pulmonary homograft dysfunction. J Cardiovasc Surg (Torino) 2024; 65:76-78. [PMID: 38345548 DOI: 10.23736/s0021-9509.24.12725-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
Pulmonary homograft dysfunction is challenging to treat in patients with a previous Ross procedure, and results in significant morbidity and mortality in case of reoperation. We report the case of a patient with early severe pulmonary homograft stenosis 18 months after a Ross procedure and successful management using transcatheter pulmonary valve replacement.
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Affiliation(s)
- Marie-Catherine Morgant
- Department of Cardiovascular and Thoracic Surgery, Dijon University Hospital, Dijon, France -
| | - Chloé Bernard
- Department of Cardiovascular and Thoracic Surgery, Dijon University Hospital, Dijon, France
| | - Luc Lorgis
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Olivier Bouchot
- Department of Cardiovascular and Thoracic Surgery, Dijon University Hospital, Dijon, France
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Conci L, Laufer G, Zimpfer D, Andreeva A, Kocher A, Austin C, Osorio-Jaramillo E. Ross procedure with personalized external aortic root support. Multimed Man Cardiothorac Surg 2023; 2023. [PMID: 37942704 DOI: 10.1510/mmcts.2023.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
The Ross-Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in the aortic position to replace the malfunctioning aortic valve and a homograft is implanted in the pulmonary position. To prevent autograft dilatation, a Personalized External Aortic Root Support prosthesis is included in the proximal autograft anastomosis and wrapped around the ascending aorta. The aorta is transected transversely, the aortic valve is resected, and the coronary arteries are mobilized and cut out of the sinuses, leaving a rim. The pulmonary autograft is harvested by transecting the pulmonary artery and part of the right ventricular outflow tract. The autograft is approximated to the aortic root and inverted inside the ventricle. The proximal anastomosis is performed including the prosthesis between the aortic root and the autograft. The coronary buttons are threaded through appropriately positioned and sized holes in the prosthesis and reimplanted into the autograft. The ascending aorta is appropriately adapted and anastomosed with the distal autograft. When the patient is off cardiopulmonary bypass, the prosthesis can be closed longitudinally and is anchored to the distal aortic adventitia.
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Affiliation(s)
- Luca Conci
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Division of Cardiac Surgery Medical University of Vienna Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery Medical University of Vienna Spitalgasse 23, A1090 Vienna, Austria
| | - Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alfred Kocher
- Division of Cardiac Surgery Medical University of Vienna Vienna Austria
| | - Conal Austin
- Cardiac Surgery, Guy's and St Thomas' Hospital, London, United Kingdom
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Liang M, Tang Z, Huang C. Commentary: Live long and prosper: Enhanced biomechanics of pulmonary autograft using inclusion technique in Ross procedure. J Thorac Cardiovasc Surg 2023; 165:e117-e118. [PMID: 34362572 DOI: 10.1016/j.jtcvs.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhixian Tang
- Department of Thoracic Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Chen Huang
- Department of Thoracic Surgery, Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University, Fuzhou, China.
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Zhu Y, Marin-Cuartas M, Park MH, Imbrie-Moore AM, Wilkerson RJ, Madira S, Mullis DM, Woo YJ. Ex vivo biomechanical analysis of the Ross procedure using the modified inclusion technique in a 3-dimensionally printed left heart simulator. J Thorac Cardiovasc Surg 2023; 165:e103-e116. [PMID: 34625236 PMCID: PMC8924018 DOI: 10.1016/j.jtcvs.2021.06.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/31/2021] [Accepted: 06/14/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The inclusion technique was developed to reinforce the pulmonary autograft to prevent dilation after the Ross procedure. Anticommissural plication (ACP), a modification technique, can reduce graft size and create neosinuses. The objective was to evaluate pulmonary valve biomechanics using the inclusion technique in the Ross procedure with and without ACP. METHODS Seven porcine and 5 human pulmonary autografts were harvested from hearts obtained from a meat abattoir and from heart transplant recipients and donors, respectively. Five additional porcine autografts without reinforcement were used as controls. The Ross procedure was performed using the inclusion technique with a straight polyethylene terephthalate graft. The same specimens were tested both with and without ACP. Hemodynamic parameter data, echocardiography, and high-speed videography were collected via the ex vivo heart simulator. RESULTS Porcine autograft regurgitation was significantly lower after the use of inclusion technique compared with controls (P < .01). ACP compared with non-ACP in both porcine and human pulmonary autografts was associated with lower leaflet rapid opening velocity (3.9 ± 2.4 cm/sec vs 5.9 ± 2.4 cm/sec; P = .03; 3.5 ± 0.9 cm/sec vs 4.4 ± 1.0 cm/sec; P = .01), rapid closing velocity (1.9 ± 1.6 cm/sec vs 3.1 ± 2.0 cm/sec; P = .01; 1.8 ± 0.7 cm/sec vs 2.2 ± 0.3 cm/sec; P = .13), relative rapid opening force (4.6 ± 3.0 vs 7.7 ± 5.2; P = .03; 3.0 ± 0.6 vs 4.0 ± 2.1; P = .30), and relative rapid closing force (2.5 ± 3.4 vs 5.9 ± 2.3; P = .17; 1.4 ± 1.3 vs 2.3 ± 0.6; P = .25). CONCLUSIONS The Ross procedure using the inclusion technique demonstrated excellent hemodynamic parameter results. The ACP technique was associated with more favorable leaflet biomechanics. In vivo validation should be performed to allow direct translation to clinical practice.
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Affiliation(s)
- Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Bioengineering, Stanford University, Stanford, Calif
| | - Mateo Marin-Cuartas
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Annabel M Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Robert J Wilkerson
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Sarah Madira
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Danielle M Mullis
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif; Department of Bioengineering, Stanford University, Stanford, Calif.
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12
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da Costa FDA. Commentary: Preventing pulmonary autograft dilatation: Many unanswered questions. J Thorac Cardiovasc Surg 2023; 165:e118-e119. [PMID: 34303532 DOI: 10.1016/j.jtcvs.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
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El Sherif N, Dearani JA, Connolly HM, Bagameri G, Pochettino A, Stulak JM, Stephens EH. Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era. Ann Thorac Surg 2023; 115:633-639. [PMID: 35644264 DOI: 10.1016/j.athoracsur.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/04/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Ross procedure has several advantages, but the need for reintervention is inevitable. The aim of this study was to examine the complexity and outcomes of reoperation after the Ross procedure. METHODS Retrospective chart review was performed of patients with a prior Ross procedure who underwent reoperation at our institution from September 1991 to January 2021. Demographic, echocardiographic, surgical, and perioperative data were collected. Descriptive statistical and regression analyses were performed. RESULTS A total of 105 patients underwent a reoperation at Mayo Clinic after the initial Ross procedure performed at our institution (n = 16; 16.2%) or elsewhere (n = 83; 83.8%). Mean age at the Ross procedure was 27 ± 17 years, and mean age at reoperation at our institution was 37 ± 19 years. Indications for surgical procedure varied, but 64% had autograft regurgitation as 1 of their indications for reoperation. Autograft interventions were performed in 78 patients (74.2%). Pulmonary valve or conduit replacement was performed in 56 patients (53.3%). Double root replacement was performed in 11 patients (10.5%). Aortic reconstruction was performed in 37 patients (38.4%). There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%). Patients with ejection fraction <30% on preoperative echocardiography had shorter duration between the Ross procedure and subsequent reoperation (P = .03). CONCLUSIONS Reoperations after the Ross procedure are performed for a wide range of indications, with most due to autograft dysfunction. The number of early deaths is not low. Reoperation after the Ross procedure should be advised before left ventricular systolic dysfunction.
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Affiliation(s)
- Nibras El Sherif
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Rajab TK, Ochoa B, Zilinskas K, Kwon J, Taylor CL, Henderson HT, Savage AJ, Kavarana M, Turek JW, Costello JM. Partial heart transplantation for pediatric heart valve dysfunction: A clinical trial protocol. PLoS One 2023; 18:e0280163. [PMID: 36749770 PMCID: PMC9904480 DOI: 10.1371/journal.pone.0280163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/20/2022] [Indexed: 02/08/2023] Open
Abstract
Congenital heart defects are the most common type of birth defects in humans and frequently involve heart valve dysfunction. The current treatment for unrepairable heart valves involves valve replacement with an implant, Ross pulmonary autotransplantation, or conventional orthotopic heart transplantation. Although these treatments are appropriate for older children and adults, they do not result in the same efficacy and durability in infants and young children for several reasons. Heart valve implants do not grow with the. Ross pulmonary autotransplants have a high mortality rate in neonates and are not feasible if the pulmonary valve is dysfunctional or absent. Furthermore, orthotopic heart transplants invariably fail from ventricular dysfunction over time. Therefore, the treatment of irreparable heart valves in infants and young children remains an unsolved problem. The objective of this single-arm, prospective study is to offer an alternative solution based on a new type of transplant, which we call "partial heart transplantation." Partial heart transplantation differs from conventional orthotopic heart transplantation because only the part of the heart containing the heart valve is transplanted. Similar to Ross pulmonary autotransplants and conventional orthotopic heart transplants, partial heart transplants contain live cells that should allow it to grow with the recipient child. Therefore, partial heart transplants will require immunosuppression. The risks from immunosuppression can be managed, as seen in conventional orthotopic heart transplant recipients. Stopping immunosuppression will simply turn the growing partial heart transplant into a non-growing homovital homograft. Once this homograft deteriorates, it can be replaced with a durable adult-sized mechanical implant. The protocol for our single-arm trial is described. The ClinicalTrials.gov trial registration number is NCT05372757.
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Affiliation(s)
- Taufiek Konrad Rajab
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, United States of America
- * E-mail:
| | - Brielle Ochoa
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Kasparas Zilinskas
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Jennie Kwon
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Carolyn L. Taylor
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Heather T. Henderson
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Andrew J. Savage
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Minoo Kavarana
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Joseph W. Turek
- Department of Surgery, Duke University Hospitals, Durham, North Carolina, United States of America
| | - John M. Costello
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States of America
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Zhu Y, Wilkerson RJ, Pandya PK, Mullis DM, Wu CA, Madira S, Marin-Cuartas M, Park MH, Imbrie-Moore AM, Woo YJ. Biomechanical Engineering Analysis of Pulmonary Valve Leaflet Hemodynamics and Kinematics in the Ross Procedure. J Biomech Eng 2023; 145:011005. [PMID: 35864775 PMCID: PMC9445321 DOI: 10.1115/1.4055033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/25/2022] [Indexed: 11/08/2022]
Abstract
The Ross procedure using the inclusion technique with anticommissural plication (ACP) is associated with excellent valve hemodynamics and favorable leaflet kinematics. The objective was to evaluate individual pulmonary cusp's biomechanics and fluttering by including coronary flow in the Ross procedure using an ex vivo three-dimensional-printed heart simulator. Ten porcine and five human pulmonary autografts were harvested from a meat abattoir and heart transplant patients. Five porcine autografts without reinforcement served as controls. The other autografts were prepared using the inclusion technique with and without ACP (ACP and NACP). Hemodynamic and high-speed videography data were measured using the ex vivo heart simulator. Although porcine autografts showed similar leaflet rapid opening and closing mean velocities, human ACP compared to NACP autografts demonstrated lower leaflet rapid opening mean velocity in the right (p = 0.02) and left coronary cusps (p = 0.003). The porcine and human autograft leaflet rapid opening and closing mean velocities were similar in all three cusps. Porcine autografts showed similar leaflet flutter frequencies in the left (p = 0.3) and noncoronary cusps (p = 0.4), but porcine NACP autografts versus controls demonstrated higher leaflet flutter frequency in the right coronary cusp (p = 0.05). The human NACP versus ACP autografts showed higher flutter frequency in the noncoronary cusp (p = 0.02). The leaflet flutter amplitudes were similar in all three cusps in both porcine and human autografts. The ACP compared to NACP autografts in the Ross procedure was associated with more favorable leaflet kinematics. These results may translate to the improved long-term durability of the pulmonary autografts.
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Affiliation(s)
- Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304; Department of Bioengineering, Stanford University, Stanford, CA 94304
| | - Robert J. Wilkerson
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304
| | - Pearly K. Pandya
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304; Department of Mechanical Engineering, Stanford University, Stanford, CA 94304
| | - Danielle M. Mullis
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304
| | - Catherine A. Wu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304
| | - Sarah Madira
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304
| | - Mateo Marin-Cuartas
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304; University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig 04289, Germany
| | - Matthew H. Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304; Department of Mechanical Engineering, Stanford University, Stanford, CA 94304
| | - Annabel M. Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304; Department of Mechanical Engineering, Stanford University, Stanford, CA 94304
| | - Y. Joseph Woo
- Falk Cardiovascular Research Center Department of Cardiothoracic Surgery, Stanford University, MD 300 Pasteur Drive, Stanford, CA 94305; Department of Bioengineering, Stanford University, Stanford, CA 94304
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16
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Shih E, Brinkman WT, Harrington KB, Squiers JJ, Rahimighazikalayeh G, DiMaio JM, Ryan WH. Outcomes of Redo Operations after Ross procedure. J Thorac Cardiovasc Surg 2022; 165:1803-1812.e2. [PMID: 36028359 DOI: 10.1016/j.jtcvs.2022.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/29/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Ross procedure is not commonly performed, owing to the procedural complexity and the risk of autograft and/or homograft reoperation. This study examined outcomes of patients undergoing Ross reinterventions at a dedicated Ross center. METHODS We retrospectively reviewed 225 consecutive patients who underwent a Ross procedure between 1994 and 2019. Index and redo operation characteristics and outcomes were compared between patients with and those without redo operations. Multivariate analysis was used to identify independent predictors of Ross-related reinterventions. Survival was estimated with Kaplan-Meier analysis. RESULTS Sixty-six patients (29.3%) required redo Ross surgery, 41 patients (18.2%) underwent autograft reoperation only, 8 patients (3.6%) had a homograft reintervention, and 17 patients (7.6%) had both autograft and homograft reoperations (12 as a combined procedure and 5 as sequential procedures). The mean time to reintervention was 11 ± 6 years for autograft reoperations and 12 ± 7 years for homograft reoperations. Patients who underwent Ross-related reinterventions were younger (mean, 38 ± 11 years vs 43 ± 11 years; P < .01) and had a higher rate of New York Heart Association class III/IV (56% vs 38%; P = .02) at the index Ross procedure. Most patients undergoing autograft reintervention had aortic insufficiency and/or aneurysm (98.2%; 57 of 58). The primary reason for homograft reintervention was pulmonary stenosis (92%; 23 of 25). The operative mortality of Ross reintervention was 1.5% (1 of 66). Survival at 15 years was similar in patients who required a redo operation and those who did not (91.2% vs 93.9%; P = .23). CONCLUSIONS Ross reinterventions can be performed safely and maintain patients at the normal life expectancy restored by the index Ross procedure up to 15 years at experienced centers.
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Affiliation(s)
- Emily Shih
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex; Baylor Scott and White Research Institute, Dallas, Tex.
| | - William T Brinkman
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - John J Squiers
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | | | - J Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex; Baylor Scott and White Research Institute, Dallas, Tex
| | - William H Ryan
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
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Bryan AY, Brandon Strong E, Kidambi S, Gilligan-Steinberg S, Bennett-Kennett R, Lee JY, Imbrie-Moore A, Moye SC, Hendrickx-Rodriguez S, Wang H, Dauskardt RH, Joseph Woo Y, Ma MR. Biomechanical Analysis of the Ross Procedure in an Ex Vivo Left Heart Simulator. World J Pediatr Congenit Heart Surg 2022; 13:166-174. [PMID: 35238706 DOI: 10.1177/21501351211070288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neo-aortic pulmonary autografts often experience root dilation and valve regurgitation over time. This study seeks to understand the biomechanical differences between aortic and neo-aortic pulmonary roots using a heart simulator. METHODS Porcine aortic, neo-aortic pulmonary, and pulmonary roots (n = 6) were mounted in a heart simulator (parameters: 100 mm Hg, 37 °C, 70 cycles per minute, 5.0 L/min cardiac output). Echocardiography was used to study root distensibility (percentage change in luminal diameter between systole and diastole) and valve function. Leaflet motion was tracked with high-speed videography. After 30 min in the simulator, leaflet thickness (via cryosectioning), and multiaxial modulus (via lenticular hydrostatic deformation testing) were obtained. RESULTS There were no significant differences between aortic and neo-aortic pulmonary leaflet motion, including mean opening velocity (218 vs 248 mm/s, P = .27) or mean closing velocity (116 vs 157 mm/s, P = .12). Distensibility was similar between aortic (8.5%, 1.56 mm) and neo-aortic pulmonary (7.8%, 1.12 mm) roots (P = .59). Compared to virgin controls, native pulmonic roots exposed to systemic pressure for 30 min had reduced leaflet thickness (630 vs 385 µm, P = .049) and a reduced Young's modulus (3,125 vs 1,089 kPa, P = .077). In contrast, the aortic roots exposed to pressure displayed no significant difference in aortic leaflet thickness (1,317 vs 1,256 µm, P = .27) or modulus (5,931 vs 3,631 kPa, P = .56). CONCLUSIONS Neo-aortic pulmonary roots demonstrated equivalence in valve function and distensibility but did experience changes in biomechanical properties and morphology. These changes may contribute to long-term complications associated with the Ross procedure.
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Affiliation(s)
- Amelia Y Bryan
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
- Department of Materials Science and Engineering, Stanford University, Palo Alto, CA, USA
| | - E Brandon Strong
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
- Department of Materials Science and Engineering, Stanford University, Palo Alto, CA, USA
| | - Sumanth Kidambi
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
| | | | - Ross Bennett-Kennett
- Department of Materials Science and Engineering, Stanford University, Palo Alto, CA, USA
| | - James Y Lee
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
| | - Annabel Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
- Department of Mechanical Engineering, Stanford University, Palo Alto, CA, USA
| | - Stephen C Moye
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
| | | | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
| | - Reinhold H Dauskardt
- Department of Materials Science and Engineering, Stanford University, Palo Alto, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
- Department of Bioengineering, Stanford University, Palo Alto, CA, USA
| | - Michael R Ma
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, USA
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Abstract
PURPOSE OF REVIEW The purpose of this article is to describe the optimized approach to nonrepairable aortic valve disease in young adults with a Ross procedure, while preserving the dynamic physiology of the aortic root. RECENT FINDINGS As the techniques for supporting pulmonary autografts continue to be refined, and the applicability of the Ross procedure continues to expand, an assessment of the various techniques based on aortic root physiology is warranted. Semi-resorbable scaffolds show promise in ovine models for improving the Ross procedure. Recent long-term outcomes for the Dacron inclusion technique in comparison to more physiologic methods of support emphasize the importance of balancing the prevention of early dilatation with the preservation of root haemodynamics. As this review will synthesize, the dynamic physiology of the root may be preserved even in patients at a higher risk of autograft dilatation. SUMMARY The favourable long-term outcomes of the Ross procedure can be partly attributed to the ability of the autograft to restore dynamism to the neoaortic root. Patient-specific modifications that respect root physiology can tailor the Ross procedure to address each patient's risk factors for early dilatation and late failure. As such, the Ross procedure should be recognized as an increasingly favourable solution for a wide spectrum of nonpreservable aortic valve disease in young adults.
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Affiliation(s)
| | | | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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El Arid JM, Dion F, Neville P, Lefort B. Eversion for Stabilization: A Standardized Technique for Pulmonary Autograft Inclusion. Ann Thorac Surg 2022; 114:e217-e218. [PMID: 35031293 DOI: 10.1016/j.athoracsur.2021.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/18/2021] [Accepted: 12/05/2021] [Indexed: 11/18/2022]
Abstract
We have developed a new technique avoiding autograft distortion and narrowing at inclusion during Ross procedure, in order to preserve the functional anatomy and the process of adaptation.
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Affiliation(s)
- Jean-Marc El Arid
- Department of Congenital Cardiac Surgery, Centre Hospitalier Régional Universitaire and François Rabelais University, Tours, France.
| | - Fanny Dion
- Department of Congenital Cardiac Surgery, Centre Hospitalier Régional Universitaire and François Rabelais University, Tours, France
| | - Paul Neville
- Department of Congenital Cardiac Surgery, Centre Hospitalier Régional Universitaire and François Rabelais University, Tours, France
| | - Bruno Lefort
- Department of Congenital Cardiac Surgery, Centre Hospitalier Régional Universitaire and François Rabelais University, Tours, France
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Uiterwijk M, van der Valk DC, van Vliet R, de Brouwer IJ, Hooijmans CR, Kluin J. Pulmonary valve tissue engineering strategies in large animal models. PLoS One 2021; 16:e0258046. [PMID: 34610023 PMCID: PMC8491907 DOI: 10.1371/journal.pone.0258046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/16/2021] [Indexed: 01/10/2023] Open
Abstract
In the last 25 years, numerous tissue engineered heart valve (TEHV) strategies have been studied in large animal models. To evaluate, qualify and summarize all available publications, we conducted a systematic review and meta-analysis. We identified 80 reports that studied TEHVs of synthetic or natural scaffolds in pulmonary position (n = 693 animals). We identified substantial heterogeneity in study designs, methods and outcomes. Most importantly, the quality assessment showed poor reporting in randomization and blinding strategies. Meta-analysis showed no differences in mortality and rate of valve regurgitation between different scaffolds or strategies. However, it revealed a higher transvalvular pressure gradient in synthetic scaffolds (11.6 mmHg; 95% CI, [7.31-15.89]) compared to natural scaffolds (4,67 mmHg; 95% CI, [3,94-5.39]; p = 0.003). These results should be interpreted with caution due to lack of a standardized control group, substantial study heterogeneity, and relatively low number of comparable studies in subgroup analyses. Based on this review, the most adequate scaffold model is still undefined. This review endorses that, to move the TEHV field forward and enable reliable comparisons, it is essential to define standardized methods and ways of reporting. This would greatly enhance the value of individual large animal studies.
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Affiliation(s)
- M. Uiterwijk
- Heart Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - D. C. van der Valk
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - R. van Vliet
- Faculty of medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - I. J. de Brouwer
- Faculty of medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - C. R. Hooijmans
- Department for Health Evidence Unit SYRCLE, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J. Kluin
- Heart Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
- * E-mail:
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Christ T, Paun AC, Grubitzsch H, Holinski S, Falk V, Dushe S. Long-term results after the Ross procedure with the decellularized AutoTissue Matrix P® bioprosthesis used for pulmonary valve replacement. Eur J Cardiothorac Surg 2020; 55:885-892. [PMID: 30508165 DOI: 10.1093/ejcts/ezy377] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/25/2018] [Accepted: 10/04/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Since 1967, the Ross procedure has been performed to treat aortic valve disease using homografts for pulmonary valve replacement. The decellularized Matrix P® prosthesis was developed to overcome (some) limitations of homografts. Until now, the long-term outcome data have been unavailable. METHODS Between 2002 and 2010, the Ross procedures using the Matrix P prosthesis were performed in 492 adult patients (mean age 57.2 ± 10.6 years, range 21-73 years) at our institution. Patient data were prospectively collected and analysed (3617.3 patient-years, mean follow-up 7.7 ± 4.3 years). Completeness of follow-up at 1, 5 and 10 years was 98.4%, 94.5% and 91.0%, respectively. RESULTS Hospital mortality was 3.9% (n = 19). During follow-up, 121 patients died resulting in a survival rate at 5, 10 and 12.5 years of 82.8 ± 1.7%, 70.4 ± 2.3% and 62.4 ± 2.9%, respectively. Echocardiography revealed a high incidence of relevant dysfunction of the Matrix P prosthesis and subsequent right ventricular failure. Primary reoperation/reintervention was necessary for 150 Matrix P and 48 autografts. Freedom from pulmonary valve reoperation at 5, 10 and 12.5 years was 76.2 ± 2.1%, 58.6 ± 2.9% and 53.4 ± 3.4%, respectively. The autograft function and the left ventricular function showed similar results as previously reported with a freedom from autograft reoperation at 5, 10 and 12.5 years of 91.8 ± 1.4%, 86.1 ± 2.0% and 86.1 ± 2.0%, respectively. CONCLUSIONS The Matrix P prosthesis used for the right ventricular outflow tract reconstruction in the Ross procedure showed unfavourable long-term echocardiographic results with a high rate of reoperation/reintervention for structural pulmonary valve failure. As a consequence, long-term survival of this patient cohort was impaired. Based on these findings, the use of the Matrix P prosthesis for pulmonary valve replacement for Ross procedures in adults should not be recommended.
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Affiliation(s)
- Torsten Christ
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexandru Claudiu Paun
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Holinski
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Simon Dushe
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Emmott A, Hertig V, Bergeron A, Villeneuve L, Lefebvre L, Leask RL, Calderone A, El-Hamamsy I. Distinct Expression of Nonmuscle Myosin IIB in Pulmonary Arteries of Patients With Aortic Stenosis vs Insufficiency Undergoing a Ross Procedure. Can J Cardiol 2020; 37:47-56. [PMID: 32544488 DOI: 10.1016/j.cjca.2020.02.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clinical studies have revealed a greater risk of pulmonary autograft dilation after the Ross procedure in patients with preoperative aortic insufficiency (AI). The present study examined whether the morphologic, biomechanical, and cellular properties of the pulmonary artery (PA) from patients with AI were phenotypically different compared with patients diagnosed with aortic stenosis (AS). METHODS PA segments were harvested from patients undergoing the Ross procedure for AS (n = 16) and AI (n = 6). Preoperative aortic annulus was significantly larger (P < 0.05) in patients with AI (28.5 ± 1.8 mm) vs AS (22.8 ± 1.2 mm). Morphologic, biomechanical, and cellular phenotypes of the PA were analyzed. RESULTS Collagen and elastin content in the media of the PA wall were similar in patients with AS and AI. Elastic modulus and energy loss of the PA were not significantly different between the groups. In the media of the PA, expression of a panel of vascular smooth muscle cell-specific proteins were similar in patients with AS and AI. In contrast, nonmuscle myosin IIB protein levels in the PA of AS patients were significantly higher compared with AI patients, and immunofluorescence identified staining in α-smooth muscle actin-positive vascular smooth muscle cells. CONCLUSIONS Despite similar morphological and biomechanical properties, the disparate expression of nonmuscle myosin IIB protein distinguishes the PA of patients with AI from patients with AS. The biological role in vascular smooth muscle cells and the potential contribution of nonmuscle myosin IIB to pulmonary autograft dilation in a subset of AI patients after the Ross procedure remain to be determined.
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Affiliation(s)
- Alexander Emmott
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Chemical Engineering, McGill University, Montréal, Québec, Canada
| | - Vanessa Hertig
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada
| | - Alexandre Bergeron
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada
| | - Louis Villeneuve
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada
| | - Laurence Lefebvre
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Richard L Leask
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Pharmacology and Physiology, Université de Montréal, Montréal, Québec, Canada
| | - Angelino Calderone
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Pharmacology and Physiology, Université de Montréal, Montréal, Québec, Canada
| | - Ismail El-Hamamsy
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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23
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Goecke T, Theodoridis K, Tudorache I, Ciubotaru A, Cebotari S, Ramm R, Höffler K, Sarikouch S, Vásquez Rivera A, Haverich A, Wolkers WF, Hilfiker A. In vivo performance of freeze-dried decellularized pulmonary heart valve allo- and xenografts orthotopically implanted into juvenile sheep. Acta Biomater 2018; 68:41-52. [PMID: 29191508 DOI: 10.1016/j.actbio.2017.11.041] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/10/2017] [Accepted: 11/14/2017] [Indexed: 11/16/2022]
Abstract
The decellularization of biological tissues decreases immunogenicity, allows repopulation with cells, and may lead to improved long-term performance after implantation. Freeze drying these tissues would ensure off-the-shelf availability, save storage costs, and facilitates easy transport. This study evaluates the in vivo performance of freeze-dried decellularized heart valves in juvenile sheep. TritonX-100 and sodium dodecylsulfate decellularized ovine and porcine pulmonary valves (PV) were freeze-dried in a lyoprotectant sucrose solution. After rehydration for 24 h, valves were implanted into the PV position in sheep as allografts (fdOPV) and xenografts (fdPPV), while fresh dezellularized ovine grafts (frOPV) were implanted as controls. Functional assessment was performed by transesophageal echocardiography at implantation and at explantation six months later. Explanted grafts were analysed histologically to assess the matrix, and immunofluorescence stains were used to identify the repopulating cells. Although the graft diameters and orifice areas increased, good function was maintained, except for one insufficient, strongly deteriorated frOPV. Cells which were positive for either endothelial or interstitial markers were found in all grafts. In fdPPV, immune-reactive cells were also found. Our findings suggest that freeze-drying does not alter the early hemodynamic performance and repopulation potential of decellularized grafts in vivo, even in the challenging xenogeneic situation. Despite evidence of an immunological reaction for the xenogenic valves, good early functionalities were achieved. STATEMENT OF SIGNIFICANCE Decellularized allogeneic heart valves show excellent results as evident from large animal experiments and clinical trials. However, a long-term storing method is needed for an optimal use of this limited resource in the clinical setting, where an optimized matching of graft and recipient is requested. As demonstrated in this study, freeze-dried and freshly decellularized grafts reveal equally good results after implantation in the juvenile sheep concerning function and repopulation with recipients' cells. Thus, freeze-drying arises as a promising method to extend the shelf-life of valvular grafts compared to those stored in antibiotic-solution as currently practised.
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Affiliation(s)
- Tobias Goecke
- 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
| | - 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
| | - Anatol Ciubotaru
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, 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
| | - Robert Ramm
- 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
| | - Samir Sarikouch
- Department of Cardiac-, Thoracic-, Transplantation and Vascular Surgery, 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
| | - Willem F Wolkers
- Institute of Multiphase Processes, Leibniz Universität Hannover, Hannover, Germany
| | - Andres Hilfiker
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany.
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24
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Aly Ghoneim
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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25
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Karliova I, Hagendorff A, Shalabi A, Schneider U, Schäfers HJ. Repair of a Quadricuspid Autograft. Ann Thorac Surg 2018; 105:e251-e253. [PMID: 29305147 DOI: 10.1016/j.athoracsur.2017.11.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/19/2022]
Abstract
Aortic valve replacement using a pulmonary autograft is an accepted option in children and young patients. The use of a pulmonary valve with congenital anomaly as autograft is controversial. We describe a case in which a quadricuspid pulmonary valve was used as an autograft in childhood. The patient presented with severe regurgitation 13 years later. Repair was performed with stabilization of the root and cusp prolapse correction, leading to normalized valve function. Despite concerns over the long-term durability of an anomalous pulmonary valve as autograft, good mid to long-term results can be achieved.
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Affiliation(s)
- Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg-Saar, Germany.
| | - Andreas Hagendorff
- Department of Cardiology and Angiology, University of Leipzig, Leipzig, Germany
| | - Ahmad Shalabi
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg-Saar, Germany
| | - Ulrich Schneider
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg-Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg-Saar, Germany
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26
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Wang A, Ganapathi AM, Wang A, Hughes GC. The Modified Ross Procedure with Prosthetic Graft Wrap Does Not Prevent Autograft Failure. J Heart Valve Dis 2017; 26:735-737. [PMID: 30207127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The modified Ross procedure, which involves replacement of the aortic valve with a pulmonary autograft root supported within a Dacron tube graft, was developed with the goal of preventing late autograft dilatation and associated aortic insufficiency. The case is reported of an adult patient who had a bicuspid aortic valve (BAV), underwent a modified Ross procedure, and developed severe aortic insufficiency within one year and subsequently required reoperation for aortic valve replacement. While advances have been made to increase the success of the Ross procedure via modifications to prevent aortic root dilatation, no modifications have yet been devised to improve the ability of the pulmonary valve to withstand systemic aortic pressures. The Ross procedure has significant advantages for children, but the risks and benefits should be carefully considered in adults, especially in those with BAV.
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Affiliation(s)
- Alice Wang
- Duke University Medical Center, Durham, NC, USA
| | | | - Andrew Wang
- Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- Duke University Medical Center, Durham, NC, USA, Electronic correspondence:
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Schnittman SR, Weiss AJ, Varghese R, Stelzer P. Ross Procedure Following a Dislodged Transcatheter Aortic Valve Replacement. J Heart Valve Dis 2017; 26:600-602. [PMID: 29762933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A 36-year-old pregnant woman with a history of rheumatic heart disease and prior aortic valve replacement and mitral valve repair presented to an outside hospital with severe aortic stenosis. The patient had a cardiac arrest upon labor induction and underwent a transcatheter aortic valve replacement (TAVR), which dislodged two days later. Five months later, the patient underwent removal of the dislodged TAVR and a Ross procedure at the authors' institution. The patient was stable upon discharge, with minimal aortic and pulmonary regurgitation. To the authors' knowledge, the present report is the first of the Ross procedure being used under such circumstances. It is suggested that caution be taken when using bioprosthetic and transcatheter aortic valves in young patients, and primary use of the Ross procedure is encouraged at experienced centers.
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Affiliation(s)
- Samuel R Schnittman
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aaron J Weiss
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robin Varghese
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paul Stelzer
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic correspondence:
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28
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Heidary Rouchi A, Radmehr H, Tavakoli SA, Jafarzadeh Kashi TS, Mahdavi-Mazdeh M. Iranian homograft heart valves: assessment of durability and late outcome. Cell Tissue Bank 2016; 17:603-610. [PMID: 27501816 DOI: 10.1007/s10561-016-9573-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/29/2016] [Indexed: 11/26/2022]
Abstract
Durability and the rate of complications of homograft heart valves, adjusted for patient-related contributors and surgical techniques, rely mainly on the quality of allografts which in turn are mirrored in the donor characteristics and most importantly recovery and processing procedures. Aimed to assess the quality, a study was conducted to figure out the durability and late outcome following homograft replacement with valved conduits procured by the Iranian Tissue Bank. Retrospectively, the pre-implantation, perioperative and follow-up data of 400 non-consecutive recipients of cryopreserved heart valves (222 pulmonary and 178 aortic) from 2006 to 2015 were collected and analyzed in terms of variables reflecting late outcome including adverse events and durability. In the context of durability, the event of interest was defined as the need for homograft replacement and homograft-related death. The mean follow-up time (SD) of study entrants (male/female ratio, 1.4) was 49.8 (36.3) months. Median age at the time of implantation was 11 years. Total 10-years mortality was 21 % (84/400), including 66.7 % early (30-days mortality: 56/84) and 33.3 % late (28/84). Overall late complication rate was 2 %. Median survival time was 120 months (95 % CI 83.3-156.6). The pulmonary valves appeared to be more durable (P value <0.001) and survival probabilities in small sized grafts were lower (P value 0.008). One-, five-, and ten-year graft survival was 82, 76 and 73 %, respectively. The evidences suggest that the homografts function satisfactory with low rate of late complications; nevertheless, more emphasis should be given to make long-term durability comparable.
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Affiliation(s)
- Alireza Heidary Rouchi
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Blvd., Tehran, 1419731351, Iran
| | - Hassan Radmehr
- Department of Cardiac Surgery, Children Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Amirhosein Tavakoli
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Blvd., Tehran, 1419731351, Iran
| | | | - Mitra Mahdavi-Mazdeh
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Blvd., Tehran, 1419731351, Iran.
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29
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Abstract
The Ross procedure is being used increasingly to treat aortic valve disease in pediatric patients; however, there is an ongoing dispute about the durability of the autograft. From November 1996 to September 2003, 32 pediatric patients (mean age, 11 ± 4.5 years) underwent the Ross procedure for various aortic valve diseases, using the root replacement technique. Clinical and echocardiographic follow-up was performed early (within 30 days), at 3 to 6 months, and yearly after surgery. There were no perioperative deaths. The patients were followed-up for up to 7 years with a median interval of 36 months. Actuarial survival at 7 years was 96% ± 3% and there was 100% freedom from re-operation for autograft valve dysfunction or any other cause. The autograft annulus and sinus increased significantly in size during follow-up and the increase in size paralleled the increase in body surface area, with no evidence of disproportional dilatation. The hemodynamics at the latest follow-up were also similar to those at the time of discharge after surgery. Pulmonary autograft replacement of the aortic valve appears to be the ideal solution in pediatric patients, because of relatively low operative risk, excellent late valve function, and real potential for growth.
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Affiliation(s)
- Shahzad G Raja
- Department of Pediatric Cardiothoracic Surgery, Alder Hey Hospital, Liverpool L12 2AP, UK.
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30
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Abstract
Between 1994 and 2002, 31 patients underwent the Ross procedure by a single surgeon. The mean age was 42 years (24–61), 87% were male and 61% were in New York Heart Association (NYHA) class III–IV. Pure aortic stenosis (AS) was present in 32% of patients, pure aortic regurgitation (AR) in 22% and mixed disease in the rest. The aortic valve was bicuspid in 93.5% of the patients. Autograft implantation was by full root replacement in all cases. Concomitant cardiac surgical procedures were carried out in 10/31 (32%). All patients had at least annual clinical and echocardiographic follow-ups. There was one early death (3%). Overall patient survival was 92.7% at 1 year and 86.1% at 5 years. Twenty-eight (96.55%) were in NYHA class I. Echocardiographic follow-up revealed none to trivial AR in 24/29 (82.75%) and mild AR in 4/29 (13.7%). There was no autograft re-operation before 5 years. The mean gradient across the autograft was low (< 4 mm Hg). There were no incidences of endocarditis or thromboembolism. None of the patients required anticoagulation. Our early experience with the Ross procedure has shown good results in relation to early and midterm morbidity, mortality, autograft, and homograft function.
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Affiliation(s)
- George Matalanis
- Department of Cardiac Surgery, Austin Hospital, Studley Road, Heidelberg, Victoria 3084, Australia.
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31
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Jacobsen RM, Earing MG, Hill GD, Barnes M, Mitchell ME, Woods RK, Tweddell JS. The Externally Supported Ross Operation: Early Outcomes and Intermediate Follow-Up. Ann Thorac Surg 2015; 100:631-8. [PMID: 26141776 DOI: 10.1016/j.athoracsur.2015.04.123] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 04/17/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The externally supported Ross (supported Ross), consisting of a Dacron (DuPont, Wilmington, DE) graft to support the neoaortic root, has been used in adolescent and adult patients to prevent neoaortic dilatation. Outcomes after the supported Ross technique were compared with the Ross procedure using the standard aortic root replacement technique (standard Ross). METHODS This was a retrospective analysis of 36 adolescent and young adult patients who underwent the Ross procedure between 1992 and 2013. The outcomes of supported Ross procedures in 26 patients were compared with the Ross procedure in 10 patients. End points included survival, neoaortic root dilatation, development of neoaortic regurgitation, and the need for reintervention. RESULTS The median age at operation was 14 years (range, 11 to 31 years), and indications for the operation were mixed lesions (47%), followed by aortic regurgitation (42%) and stenosis (11%). There were no early deaths. The mean follow-up was 2.2 years (range, 1 to 11 years). At the 1-year (p = 0.01) and 3-year (p < 0.05) follow-up, patients in the supported Ross cohort had a smaller neoaortic root z-score. Neither cohort had a large number of patients with significant neoaortic regurgitation, with 1 patient in the supported cohort compared with 3 patients in the standard cohort. Overall, 4 patients (40%) in the standard Ross cohort had required reintervention, including 3 directed at the neoaortic root. One patient in the supported Ross cohort required early reintervention for revision of the right coronary artery. CONCLUSIONS At intermediate follow-up, patients who underwent the supported Ross technique were less likely to have neoaortic root dilatation compared with patients who underwent a standard Ross procedure. Further studies are needed to evaluate the long-term durability of this technique, particularly in regards to the development of significant aortic regurgitation, the rate of reintervention, and application to younger and smaller patients.
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Affiliation(s)
- Roni M Jacobsen
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Michael G Earing
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Garick D Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Barnes
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James S Tweddell
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Faganello G, Russo G, Pozzi M, Gigli M, Pagnan L, Di Lenarda A. [Pulmonary autograft dysfunction mimicking severe aortic stenosis]. G Ital Cardiol (Rome) 2015; 16:320-1. [PMID: 25994470 DOI: 10.1714/1870.20440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Qiao A, Pan Y, Dong N. Modeling study of aortic root for ross procedure: a structural finite element analysis. J Heart Valve Dis 2014; 23:683-687. [PMID: 25790614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The Ross procedure involves replacing the diseased aortic valve with the patient's own pulmonary valve (autograft) to form the neoaortic valve, reimplanting the coronary arteries, and inserting a cadaveric homograft into the pulmonary position. METHODS In order to model a neoaortic root for the Ross procedure in patients with aortic valve disease, the three-dimensional geometry of a reference aortic valve was reconstructed (reference model A). The diameters of the sinotubular junction (STJ) and maximum sinus were then modified to create four geometric models named B, C, D, and E, with different dimensions. The mechanical behavior of the aortic root was simulated, and the performance of the aortic leaflets assessed in terms of maximum geometric orifice area (GOA) during all cardiac cycle and leaflet contact pressure during closing phase. RESULTS The neoaortic valve model showed a maximum GOA of 274.4 mm2 and a maximum leaflet stress of 682 kPa. For models B and C, the leaflet contact pressure was increased by 27.4% and decreased by 4.42%, with STJ diameter increased 1.1-fold and decreased 0.9-fold compared to reference model A. The leaflet contact pressure in models D and E was increased by 3.04% and decreased by 11.5%, while the sinus diameter was increased 1.1-fold and decreased 0.9-fold compared to model A. CONCLUSION Increasing the STJ and sinus diameters within a range of 10% can increase the leaflet contact pressure for the aortic root, and vice versa. This may be the reason why neoaortic valve insufficiency occurs long after patients have undergone the Ross procedure.
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Yacoub MH, El-Hamamsy I, Sievers HH, Carabello BA, Bonow RO, Stelzer P, da Costa FDA, Schäfers HJ, Skillington P, Charitos EI, Luciani GB, Takkenberg JJM. Under-use of the Ross operation--a lost opportunity. Lancet 2014; 384:559-560. [PMID: 25131967 DOI: 10.1016/s0140-6736(14)61090-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Magdi H Yacoub
- Magdi Yacoub Institute, Imperial College, London UB9 6JH, UK.
| | | | | | | | - Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Wisneski AD, Matthews PB, Azadani AN, Mookhoek A, Chitsaz S, Guccione JM, Ge L, Tseng EE. Human pulmonary autograft wall stress at systemic pressures prior to remodeling after the Ross procedure. J Heart Valve Dis 2014; 23:377-384. [PMID: 25296465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Remodeling of the pulmonary autograft upon exposure to systemic pressure can lead to progressive dilatation and aneurysmal pathology. Remodeling is driven by changes in autograft wall stress upon exposure to systemic pressure; however, the magnitude of these changes is unknown. Previously, a porcine autograft finite element model was developed to determine wall stress, but the porcine and human material properties differed significantly. Hence, the study aim was to understand human pulmonary autograft biomechanics that lead to remodeling by determining wall stress magnitudes immediately after the Ross procedure using finite element analysis (FEA). METHODS Human pulmonary root was scanned by high-resolution microcomputed tomography to construct a realistic three-dimensional geometric mesh. Stress-strain data from biaxial stretch testing was incorporated into an Ogden hyperelastic model to describe autograft mechanical properties for an adult Ross patient. Autograft dilatation and wall stress distribution during pulmonic and systemic pressures prior to remodeling were determined using explicit FEA in LS-DYNA. RESULTS Human pulmonary autograft demonstrated non-linear material properties, being highly compliant in the low-strain region, and stiffening at high strain. The majority of dilatation occurred with < 20 mmHg pressurization. From pulmonary to systemic pressures, the increases in autograft diameter were up to 17%. Likewise, the maximal wall stress increased approximately 14.6-fold compared to diastolic pressures (from 13.0 to 190.1kPa), and six-fold compared to systolic pressures (from 48.6 to 289.6kPa). CONCLUSION The first finite element model of the human pulmonary autograft was developed and used to demonstrate how autograft material properties prevent significant dilatation upon initial exposure to systemic pressure. Mild dilatation was noted in the sinuses and sinotubular junction. Autograft wall stress was increased greatly when subjected to systemic pressures, and may trigger biomechanical remodeling of the autograft. Sustained exposure to higher wall stresses, coupled with inadequate remodeling, may lead to future autograft dilatation.
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Abstract
Prosthetic heart valves have been outpaced by progress in cardiac surgery. Early biologic valve prostheses consisted of tissues mounted on a rigid stent, and did not require anticoagulation, but rarely survived two decades. Subsequently, durable mechanical valve prostheses dominated despite, the requisite anticoagulation. The mechanical design remains imperfect, with obstruction to flow, turbulence, hematological changes and also, occasionally audible clicks. Reports documenting superior function for cryopreserved human aortic heart valves (homografts) without these problems, albeit with limited durability, followed. The marketing of 'stentless biologic valves', mimicking these attributes was a reaction to the shortage of homografts. These imperfections explain the rediscovery of the Ross operation, in which the patient's pulmonary valve (autograft) is excised to replace the aortic valve. The autograft is living tissue, complete with attributes of a healthy heart valve, including growth and durability. The pulmonary valve, where lower pressure and oxygen saturation retards degeneration, is substituted with a pulmonary homograft. The Ross operation is exacting and leaves the patient with two potentially malfunctioning valves.
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Affiliation(s)
- Cornelius A Botha
- Cardiac Clinic Bodensee (Lake Constance), Weinbergstrasse 1, Kreuzlingen, CH 8280, Switzerland.
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Ungerleider RM, Walsh M, Ootaki Y. A modification of the pulmonary autograft procedure to prevent late autograft dilatation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:38-42. [PMID: 24725715 DOI: 10.1053/j.pcsu.2014.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Although the pulmonary autograft procedure for aortic valve replacement is a commonly utilized option for children, its use is diminishing in adult-aged patients. One commonly cited concern is the tendency for the pulmonary autograft to dilate in the aortic position. This article reviews a technique we have used in 36 patients since October, 2004 that stabilizes the autograft so that it cannot dilate. There have been no operative or late deaths and the autograft has continued to function in 34 patients. Two patients have undergone autograft replacement because of early failure, which we believe was likely related to technical considerations in our early technique (first reported in the 2005 STCVS Pediatric Cardiac Surgery Annual). The technical modifications described in this article have produced a more reliable and reproducible technique and have not resulted in any autograft failures in our experience. One patient with Marfan's syndrome and a bicuspid aortic valve is symptom- and dilation-free 8 years post op, with no autograft or pulmonary homograft insufficiency, normal activity and a stable aortic root by serial echocardiography. Our results suggest that this technique might be applicable for selected adult patients in whom autograft growth is not necessary and for whom the risk of autograft dilatation would provide a reason to avoid a pulmonary autograft procedure.
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Affiliation(s)
| | - Michael Walsh
- Brenner Children's Hospital, Wake Forest University, Winston Salem, NC
| | - Yoshio Ootaki
- Brenner Children's Hospital, Wake Forest University, Winston Salem, NC
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Hazekamp MG. Reoperations after paediatric Ross operation. Eur J Cardiothorac Surg 2012; 42:31-2. [PMID: 22577097 DOI: 10.1093/ejcts/ezs133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Healy AH, Doty JR. Double freestyle valve replacement in a patient with a prior Ross procedure. J Heart Valve Dis 2012; 21:267-269. [PMID: 22645866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Following a Ross procedure, patients may require reintervention for valvular stenosis or insufficiency of either the pulmonary autograft or the pulmonary homograft. Herein is reported a double use of the Medtronic Freestyle stentless bioprosthesis in a patient who previously had undergone a Ross procedure.
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Affiliation(s)
- Aaron H Healy
- Division of Cardiovascular and Thoracic Surgery, Intermountain Medical Center, Murray, Utah 84157, USA
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Gustafson MR, Moulton MJ. Fibrosing mediastinitis with severe bilateral pulmonary artery narrowing: RV-RPA bypass with a homograft conduit. Tex Heart Inst J 2012; 39:412-415. [PMID: 22719157 PMCID: PMC3368482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Although fibrosing mediastinitis is uncommon, it is a devastating sequela of certain granulomatous diseases. The compression of mediastinal structures can lead to severe cardiopulmonary symptoms. We report the case of a 50-year-old woman who presented with severe bilateral branch pulmonary artery compression 6 months after bilateral pulmonary artery stenting. We performed bypass surgery with use of a homograft conduit. Seven months postoperatively, the homograft and stent in the right pulmonary artery were patent, and the patient had resumed activities of daily living, including full-time employment. In addition to reporting this patient's case, we discuss surgery as an alternative to stenting in patients with fibrosing mediastinitis.
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Affiliation(s)
- Monica R Gustafson
- Division of Cardiothoracic Surgery, University of Arizona College of Medicine, Tucson, Arizona 85724, USA
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Charitos EI, Stierle U, Hanke T, Bechtel M, Sievers HH, Petersen M. Pulmonary homograft morphology after the Ross procedure: a computed tomography study. J Heart Valve Dis 2011; 20:688-694. [PMID: 22655500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY In patients undergoing the Ross procedure the autograft morphological characteristics have been well studied, but those of the homograft are less clear. The study aim was to describe the radiomorphological homograft characteristics in Ross patients, and to compare them with such characteristics in normal (control) subjects. METHODS A total of 79 Ross patients (68 males, 11 females; mean age 43 +/- 12.3 years) underwent a computed tomography (CT) scan at a mean of 31 +/- 26 months after surgery. A group of 123 patients without cardiovascular disease served as controls. Cryopreserved homografts were implanted in all Ross patients, with the majority being obtained from a single source. RESULTS The mean donor age was 47 +/- 11 years, and the mean homograft diameter 25.4 +/- 1.3 mm (as provided at source). Electrocardiographic-gated CT reconstructions were used for the measurements. The smallest diameters were at the proximal anastomosis, and maximum diameters at the distal anastomosis (p <0.001). In controls, the minimum diameter was just proximal to the pulmonary valve annulus. In Ross patients, the homograft diameters were significantly smaller at all levels compared to controls. This effect persisted after taking into consideration patient age, height, gender, body surface area, and time since surgery. Notably, the measured homograft diameters were significantly smaller than those provided at source. CONCLUSION The study results provided evidence of homograft shrinkage at all levels after the Ross procedure but, most prominently, at the level of the proximal suture line. This may have implications for novel preservation methods, as well as homograft size selection and implantation techniques.
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Affiliation(s)
- Efstratios I Charitos
- University of Lübeck, Department of Cardiac and Thoracic Vascular Surgery, Lübeck, Germany.
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Mitilian D, Zargouni N, Mechmeche R, Acar C. Polyester mesh: an alternative material for reinforcing the pulmonary autograft root. J Heart Valve Dis 2011; 20:587-589. [PMID: 22066365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Today, it is widely accepted that the pulmonary autograft should be reinforced when used as a root in the Ross operation. Various techniques using a vascular conduit have been reported. Herein is described an alternative technique, using a polyester mesh, that was applied in a 15-year-old boy with recurrent congenital stenosis. The advantages of using a mesh rather than a solid vascular prosthesis are discussed.
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Affiliation(s)
- Delphine Mitilian
- Department of Cardiac Surgery, Hôpital de la Salpêtrière, Paris, France
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Kalfa D, Feier H, Loundou A, Fraisse A, Macé L, Metras D, Kreitmann B. Cryopreserved homograft in the Ross procedure: outcomes and prognostic factors. J Heart Valve Dis 2011; 20:571-581. [PMID: 22066363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The study aim was to determine the dynamics and risk factors related to cryopreserved homografts implanted to reconstruct the right ventricular outflow tract (RVOT) during the Ross procedure. METHODS A retrospective study, conducted between 1993 and 2009, included 107 consecutive patients who underwent a Ross procedure with implantation of a homograft (102 pulmonary, five aortic). The median patient age at implant was 18.8 years (range: 2 months - 67 years). The main cardiac defects were congenital aortic stenosis (n = 44), congenital aortic regurgitation (n = 20), and combined (n = 23) and acquired (n = 20) aortic regurgitation. The study endpoints were homograft stenosis (peak gradient > or = 20 mmHg), regurgitation (grade > or = moderate), homograft dysfunction (stenosis > or = 50 mmHg or regurgitation > or = moderate), homograft explant, and failure (explant or balloon dilation). The mean follow up was 5.7 +/- 0.4 years. The statistical analysis was conducted using univariate and multivariate Cox regression tests. RESULTS The overall patient survival was 97% at 18 years. Homograft stenosis occurred in 54% of patients, regurgitation in 18%, dysfunction in 27%, explant in 5%, and failure in 6%. Freedom from homograft dysfunction was 75% and 55% at five and 10 years, respectively, while freedom from homograft failure was 99% and 84% at five and 10 years, respectively. The main multivariate risk factors for dysfunction were: homograft diameter < 22 mm (OR: 11, p = 0.019), aortic homograft (OR: 18, p = 0.019) and preoperative right ventricle/left ventricle pressure ratio > 0.4 (OR: 5, p = 0.018). Univariate risk factors for failure were: homograft diameter < 22 mm (p = 0.006), donor age < 30 years (p = 0.03), cold ischemia time < 2 days (p = 0.04), and decontamination time < 12 h (p = 0.01). CONCLUSION In the Ross procedure, the cryopreserved homograft represents an excellent means to reconstruct the RVOT, with a good long-term longevity. Almost 85% of patients did not require any surgery or percutaneous intervention at 10 years after implantation. The homograft long-term durability depends on both homograft-related and patient-related factors. Pulmonary homografts, with a diameter > 22 mm, a donor age > 30 years, and a cold ischemia time > 2 days are to be preferred.
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Affiliation(s)
- David Kalfa
- Department of Cardiac and Thoracic Surgery, La Timone Children's Hospital, Marseille, France.
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Brown JW, Ruzmetov M, Shahriari A, Rodefeld MD, Turrentine MW, Mahomed Y. The Ross full root replacement in adults with bicuspid aortic valve disease. J Heart Valve Dis 2011; 20:332-340. [PMID: 21714426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Bicuspid aortic valve disease (BAVD) is the most common congenital cardiac lesion causing aortic stenosis in adults. This lesion can be associated with a histological abnormality of the aortic wall and dilated or aneurysmal ascending aorta. In younger patients, the Ross operation offers several advantages over conventional aortic valve replacement (AVR); however, the rationale of performing this procedure on adults in the face of BAVD have been questioned. METHODS Between 1994 and 2009, a total of 101 adult patients (mean age 36 years; range: 18-61 years) with BAVD underwent the Ross full root replacement at the authors' institution. Of these patients, 23 (23%) had an aneurysmal ascending aorta (4.0-5.2 cm) associated with BAVD which was resected at the time of, or subsequent to, a Ross AVR. The end point of the study was freedom from Ross autograft dilatation > 4.0 cm, dysfunction, or valve repair or replacement. RESULTS The mean follow up was 6.0 +/- 3.9 years. At the latest follow up, 19 patients (19%) had a dilated ascending aorta with a mean size 45.1 mm (range: 40-64 mm). Eight patients (8%) required a redo operation on the autograft. Three of seven patients undergoing reoperation had their autograft valve preserved; the remaining four underwent a modified Bentall root replacement. One patient had a repair of a left ventricular pseudoaneurysm below the Ross valve. Only three patients with preoperative ascending aorta dilation developed late autograft dilation. Freedom from autograft dilatation > 4.0 cm, dysfunction, repair or replacement was 80% at 10 years. CONCLUSION Mid-term results indicate that Ross AVR in adults with BAVD had good outcomes, with a low incidence of autograft-related complications. In almost half of the patients undergoing reoperation, the autograft valve was preserved. The incidence of autograft valve insufficiency and dilatation might be further reduced by: (i) aggressively treating any postoperative systemic hypertension; (ii) externally fortifying the annulus and sinotubular junction of the autograft with Dacron strips; and/or (iii) replacing a dilated ascending aorta with a Dacron interposition graft. The preoperative diagnosis of BAVD and/or aneurysmal ascending aorta is not predictive of late autograft dilatation or failure.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA
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Konertz W, Angeli E, Tarusinov G, Christ T, Kroll J, Dohmen PM, Krogmann O, Franzbach B, Pace Napoleone C, Gargiulo G. Right ventricular outflow tract reconstruction with decellularized porcine xenografts in patients with congenital heart disease. J Heart Valve Dis 2011; 20:341-347. [PMID: 21714427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Decellularized xenogeneic pulmonary valves have been introduced for right ventricular outflow tract (RVOT) reconstruction in congenital heart disease. In the present study, the intermediate-term results from three institutions were analyzed. METHODS Between January 2006 and September 2008, a total of 61 patients (median age 7 years; range: 9 days to 50 years; median body weight 21 kg; range: 1.9-140 kg) underwent RVOT reconstruction with either the Matrix P (n = 9) or Matrix P Plus (n = 52) tissue-engineered conduit. Eighteen patients underwent surgery in infancy, and 31 patients had previously undergone one or more RVOT interventions or operations. RESULTS The valve sizes ranged from 11 to 27mm. Five patients died during the hospital stay or within three months, from non-valve-related causes; hence, the early mortality was 8.2%. No deaths occurred during the follow up period. Reoperation due to valve failure became necessary in four patients; three patients underwent RVOT interventions due to distal anastomotic stenosis, and six reinterventions were performed distal to the valve due to hypoplastic branch pulmonary arteries. Patients with valve implantation during infancy showed a composite freedom from valve-related reoperation, catheter intervention or valve dysfunction (defined as dP(max) > 40 mmHg) of 87% at one and three years postoperatively. Both, computed tomography and magnetic resonance imaging studies demonstrated normal structural features, with no evidence of calcification. CONCLUSION The Matrix P/Matrix Plus conduit represents a viable alternative for RVOT reconstruction in patients with congenital heart disease. The intermediate-term performance of the conduits was favorable compared to that of other currently available implants.
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Affiliation(s)
- Wolfgang Konertz
- Departments of Cardiovascular Surgery, Charité Medical University Berlin, Germany.
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Brown JW, Ruzmetov M, Eltayeb O, Rodefeld MD, Turrentine MW. Performance of SynerGraft decellularized pulmonary homograft in patients undergoing a Ross procedure. Ann Thorac Surg 2011; 91:416-22; discussion 422-3. [PMID: 21256282 DOI: 10.1016/j.athoracsur.2010.10.069] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 10/20/2010] [Accepted: 10/22/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the Ross aortic valve replacement (AVR), a pulmonary allograft normally replaces the autotransplanted pulmonary valve. Despite the Ross advantages vs other AVR procedures, there has been a small but unpredictable risk of early structural allograft valve deterioration, usually manifested by shrinkage and right ventricular outflow tract obstruction. This study analyzed our results of the Ross AVR using a new CryoValve SynerGraft (CryoLife Inc, Kennesaw, GA) decellularized pulmonary allograft (SGDPA) and compared it with the standard cryopreserved allograft (SCA) used during the same period. METHODS Between 2000 and 2009, 29 patients received a SGDPA and 34 received the SCA during Ross AVR. Patients were a mean age at implant of 28.6 ± 16.0 years (range, 4 months to 58 years). Retrospective data included reported adverse events, and the most recent hemodynamic data were collected. RESULTS No early or late deaths or significant morbid events occurred during the mean follow-up of 4.9 ± 2.7 years (range, 2 months to 9 years). No patient required conduit reoperation. The median peak gradient at discharge was 12 mm Hg and was not significant at last follow-up. No deterioration in conduit valve function occurred in the SGDPA group. Mild conduit regurgitation developed in several SCA patients, and one patient had moderate regurgitation. No patient reached our definition of conduit dysfunction (peak gradient: 40 mm Hg or >2+ regurgitation). CONCLUSIONS The SGDPA conduit is an alternative to the SCA for the Ross AVR. The early clinical and hemodynamic results are encouraging but were not significantly different from the SCA. SynerGraft technology may provide a more durable option for patients who need right ventricular outflow tract reconstruction. Further long-term follow-up is needed to see if this decellularization process improves long-term allograft durability.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery, James W. Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA.
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Eishi K. [Transplantation of autologous pulmonary valve to the aortic valve and human frozen pulmonary valve to the position of the pulmonary valve (Ross surgery) in a patient with aortic valve regurgitation with a single coronary artery]. Kyobu Geka 2011; 64:206. [PMID: 21591482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Matthews PB, Jhun CS, Yaung S, Azadani AN, Guccione JM, Ge L, Tseng EE. Finite element modeling of the pulmonary autograft at systemic pressure before remodeling. J Heart Valve Dis 2011; 20:45-52. [PMID: 21404897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Pulmonary autograft dilatation requiring reoperation is an Achilles' heel of the Ross procedure, as exposure to systemic pressure increases autograft wall stress, which may in turn lead to tissue remodeling and aneurysmal pathology. However, the magnitude of autograft wall stress with the Ross procedure is unknown. The study aim was to develop a realistic finite element (FE) model of the autograft, and to perform simulations at systemic pressure to determine wall stress distribution immediately after the Ross operation. METHODS The porcine pulmonary root geometry was generated from high-resolution microcomputed tomography (microCT) images to create a mesh composed of hexahedral elements. Previously defined constitutive equations were used to describe the regional material properties of the native porcine pulmonary root. The anterior and posterior pulmonary arteries, and each of the pulmonary sinuses, were best described by non-linear, anisotropic Fung strain energy functions, and input individually into the model. Autograft dilatation and wall stress distribution during pulmonary and systemic loading prior to remodeling were determined using explicit FE analysis in LS-DYNA. RESULTS The autograft was highly compliant in the low-strain region, and the majority of dilation occurred with < 30 mmHg of pressurization. During pulmonic loading, a typical inflation/deflation was observed between systole and diastole, but the autograft remained almost completely dilated throughout the cardiac cycle at systemic pressure. Although the systolic blood pressure was 380% greater in the aortic than in the pulmonary position, the peak systolic diameter was increased by only 28%. The maximum principal wall stress increased approximately 10-fold during systole and 25-fold during diastole, and was greater in the sinus than the distal artery for all simulations. CONCLUSION Under systemic loading conditions, the pulmonary autograft remained fully dilated and experienced large wall stresses concentrated in the sinus. The future correlation of this model with explanted autografts may lead to an improved understanding of tissue remodeling following the Ross procedure.
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Affiliation(s)
- Peter B Matthews
- Department of Surgery, University of California at San Francisco Medical Center, San Francisco, CA 94103-0118, USA
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