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Ann Thorac Surg 1995;59:1007-1010
© 1995 The Society of Thoracic Surgeons

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Case Reports

Use of the Native Aortic Valve as the Pulmonary Valve in the Ross Procedure

Departments of Thoracic-Cardiovascular Surgery and Pediatrics, Loyola University Medical Center, Maywood, Illinois

Accepted for publication August 5, 1994.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
The placement of a foreign valve in the pulmonary position using the Ross procedure requires reoperation. To circumvent this problem, we devised a method of reimplanting the native aortic valve in the pulmonary position, and successfully performed this procedure in a 12-year-old diabetic boy operated on for the treatment of aortic insufficiency. Although diseased, the reimplanted aortic valve functioned well, with trivial stenosis and insufficiency. This modification offers patients with aortic valve disease a potentially curative operation.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
The Ross procedure requires the implantation of a foreign valve in the pulmonary position using a valve that has longevity. Currently, a cryopreserved homograft is preferred for this purpose, although other materials such as autologous fascia lata and pericardial valves have been used [1]. Valveless conduits also have been used successfully in the pulmonary position, but right ventricular dysfunction is a consequence of this.

Although cryopreserved homografts are preferred and last longer in the pulmonary position, replacement nevertheless will be necessary [2]. Early failures have also been reported and have been attributed to possible immunologic rejection [3].

To circumvent the need for pulmonary valve replacement with the Ross procedure, we devised a method of implanting the native aortic valve in the pulmonary position. This was based on our belief that a diseased aortic valve, especially when the main problem is aortic insufficiency, should function reasonably well in the pulmonary position because of the lower pulmonary vascular pressure and resistance involved. We report on our experience with this method.

A 12-year-old boy was referred to us for the treatment of congenital aortic insufficiency. Cardiac catheterization performed when he was 4 years old had shown a tricuspid aortic valve with mild incompetence. The aortic insufficiency had worsened considerably over the years. His medical history was also remarkable for juvenile diabetes, which was treated with insulin injections twice a day.

The chest radiogram revealed moderate cardiac enlargement with a globular heart. The electrocardiogram showed left ventricular hypertrophy.

Echocardiography demonstrated a tricuspid aortic valve that showed mild thickening and doming during systole. The right cusp was smaller and was somewhat fused to the left cusp. A Doppler study showed a peak systolic gradient of 20 mm Hg across the aortic valve and moderately severe aortic insufficiency with a relatively wide jet. Diastolic flow into the descending aorta indicated the presence of significant aortic insufficiency. The left ventricle showed normal function but was quite dilated (Fig 1A).

View larger version (173K): [in this window] [in a new window]   Fig 1. . (A) Preoperative echocardiogram showing a severely dilated left ventricle (LV). The diameter was 6.2 cm, versus a predicted diameter of 4.8 cm. (B) Postoperative echogram showing the size of the LV has normalized. The new aortic valve (pulmonary autograft) is competent. (C) The native aortic valve is seen in the pulmonary position (arrow). (PA = main pulmonary artery.)

The main pulmonary artery and valve were removed as an anatomic unit in preparation for the root replacement technique (Fig 2). The ascending aorta was then transected distal to the sinotubular ridge, and the coronary arteries with wide aortic cuffs were detached from the aorta. To remove the aortic valve, the edge of the leaflet was incised close to the aortic wall. A second incision was made at the noncoronary cusp on the aortic wall, allowing the aortic valve to be removed as a single unit with the aortic wall and all commissures intact. This was possible because of the high location of the commissures. The aortic annulus remained intact and sturdy, and consisted of the ventriculoarterial junction anteriorly and mitral--aortic junction posteriorly. The pulmonary autograft was anastomosed to the aortic annulus with continuous 4-0 monofilament suture. The coronary arteries were reimplanted and the distal anastomosis was done.

View larger version (26K): [in this window] [in a new window]   Fig 2. . (A) The anatomic unit of main pulmonary artery (PA) and valve was excised. After the aorta (Ao) had been transected and the left and right coronary arteries (LCA, RCA) separated, the native aortic valve was harvested. The outer hatched marks underneath the commissures indicate an extension of the incision from the coronary artery as it is being separated from the aorta. The inner hatched marks show how the leaflets were detached from the aortic wall and how this incision met the one beneath the commissures. (B, C) An intact aortic valve could be harvested because of the high location of the commissures. The aortic annulus for the root replacement was also left intact. After aortic root replacement, the native aortic valve was reimplanted in the pulmonary position using a simple continuous suture. A polytetrafluoroethylene patch was added to the new main pulmonary artery. The piece of aortic wall holding the anterior commissure was sutured higher to this patch. (LV = left ventricle; RV = right ventricle.)

The patient's postoperative course was uneventful, and he was discharged home on the fifth postoperative day. At 2 months postoperatively, he was doing well. Echocardiography at this time showed mild pulmonary stenosis (20--mm Hg gradient) and insufficiency, but the new aortic valve was competent (see Fig 1B, 1C).

	Comment

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The durability of the pulmonary valve autograft in the aortic position has been proved during 24 years of follow-up [2, 4]. The tensile strength of the pulmonary valve has been shown to be equal to or greater than that of the aortic valve [5, 6]. It has also been shown that growth or enlargement can take place without insufficiency developing [7]. Calcification has not been observed and histologic degeneration has rarely been seen [8]. Use of the pulmonary autograft seems ideal for children and young adults because the need for anticoagulation is eliminated and the need for replacement of the neoaortic valve is minimized. It has also been recommended for use in adults with a life expectancy of more than 20 years [7]. The root replacement technique with coronary artery reimplantation has simplified the placement of the pulmonary autograft, and has been associated with minimal morbidity and mortality [4, 7].

The major objection to the Ross operation, that it places both semilunar valves at risk, appears unwarranted. However, the need to implant a foreign valve in the pulmonary position remains a serious drawback. The feasibility of using the native aortic valve as a pulmonary valve in certain patients might therefore make the Ross procedure more attractive. Although the aortic valve is diseased, it should function reasonably well in the pulmonary position because of the lower pulmonary artery pressure and resistance involved. Even a stenotic aortic valve could be effectively opened with the expectation of functioning (eg, similar to an opened pulmonary valve in patients with tetralogy of Fallot). If the leaflets are shortened, they can be lengthened by the interposition of pericardium or other materials between the leaflet and the new pulmonary artery annulus. Because the valve leaflets derive their nutrient supply directly from the blood, the aortic valve in the pulmonary position should theoretically have a longevity similar to that of the pulmonary autograft.

	Footnotes

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Address reprint requests to Dr DeLeon, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Robles A, Vaughan M, Lau JK, Bodnar E, Ross DN. Long-term assessment of aortic valve replacement with autologous pulmonary valve. Ann Thorac Surg 1985;39:238–42.
2. Ross D, Jackson M, Davies J. Pulmonary autograft aortic valve replacement: long-term results. J Cardiac Surg 1992;6:529–33.
3. Clarke DR, Campbell DN, Hayward AR, Bishop DA. Degeneration of aortic valve allografts in young recipients. J Thorac Cardiovasc Surg 1993;105:934–42.
4. Kouchoukos NT, Davila-Roman VG, Spray TL, Murphy SF, Perrillo JB. Replacement of the aortic root with pulmonary autograft in children and young adults with aortic root with pulmonary autograft in children and young adults with aortic valve disease. N Engl J Med 1994;330:1–6.
5. David H, Bougner DR, Vesely I, Gerosa G. The pulmonary valve: is it mechanically suitable for use as an aortic valve replacement. ASAIO J 1994;40:206–12.
6. Gorczynski A, Trenkner M, Anisimowicz L, et al. Biomechanics of the pulmonary autograft valve in the aortic position. Thorax 1982;37:535–9.
7. Elkins RC. Pulmonary autograft-the optimal substitute for the aortic valve? N Engl J Med 1994;330:59–60.
8. Matsuki O, Okita Y, Almeida RS, et al. Two decades experience with aortic valve replacement with pulmonary autograft. J Thorac Cardiovasc Surg 1988;95:705–11.

This article has been cited by other articles:

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				K. Morishita, T. Abe, J. Fukada, H. Sato, and C. Shiiku Alternative to reconstruction of the pulmonary outflow tract in the ross procedure Ann. Thorac. Surg., August 1, 1998; 66(2): 549 - 550. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Serafin Y. DeLeon Roque Pifarré Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by DeLeon, S. Y. Articles by Pifarré, R. Search for Related Content PubMed Articles by DeLeon, S. Y. Articles by Pifarré, R.