| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1996;61:1141-1145
© 1996 The Society of Thoracic Surgeons
Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
 |
Abstract |
|---|
 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
|---|
Methods. To extend the advantages of the pulmonary autograft to this group of patients, we performed the Ross operation as a root replacement and ``fixed'' and narrowed the aortic annulus with external woven Dacron in 12 patients, Teflon felt in 5, and pericardium in 3. Twenty patients, aged 7 to 47 years (median, 27 years), are reported to assess the effectiveness of this operative technique. Preoperative aortic annulus diameter was 23 to 33 mm (13 were >27 mm).
Results. There were no operative or late deaths. Early postoperative, echocardiographic evaluation of autograft valve function revealed no significant obstruction, grade 0 aortic insufficiency in 5, trace to 1+ in 12, and 2+ in 2. Late evaluation of 1 to 4 years is available in 12 patients and has shown no increase in autograft insufficiency.
Conclusions. This experience suggests that operative fixation of the aortic annulus with an external Dacron cuff is effective and is recommended in patients with an aortic annulus that is significantly greater than normal for their body size.
|
Introduction |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
Pulmonary autograft replacement of the aortic valve is becoming the operative procedure of choice for young patients with severe aortic valve disease or left ventricular outflow tract obstruction that cannot be managed without valve replacement [1–3]. Older patients with a very active lifestyle, those patients who cannot be safely anticoagulated, and those who do not wish to be anticoagulated are candidates for the Ross operation. Enthusiasm for this procedure stems from its potential as a permanent aortic valve replacement without risk of thromboembolism and avoidance of anticoagulation.
Satisfactory long-term results have been achieved with the Ross operation, but there is an incidence of reoperation for valve dysfunction due to progressive aortic insufficiency. Ross and associates [1] reviewed their experience in 339 patients followed up for up to 24 years. Eighty-five percent of the survivors had not required reoperation. The indications for reoperation were technical errors requiring early reoperation, progressive aortic insufficiency due to inadequate coaptation of the leaflets, and bacterial endocarditis. Of 195 patients followed up at our institution 10 have required reoperation for aortic insufficiency. Of these 2 were for endocarditis, 3 for technical problems, 4 for progressive aortic insufficiency due to inadequate leaflet coaptation from progressive aortic annulus and sinotubular dilatation, and 1 for degeneration associated with systemic lupus erythematosus. Six patients required autograft replacement and 4 had successful aortic annuloplasty with correction of the aortic insufficiency.
This experience encouraged us to initiate elective aortic annuloplasty and fixation of the aortic annulus with an external ring of prosthetic material or autologous pericardium in patients with significant discrepancy between the size of the aortic annulus and the size of the pulmonary annulus. This modification of the Ross operation and its short-term results in 20 patients are reported.
|
Patients and Methods |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
. Twelve of the patients had 3 or 4+ aortic insufficiency, 7 had aortic stenosis, and 2 to 3+ aortic insufficiency and 1 had predominant aortic stenosis and 1+ aortic insufficiency. Nineteen patients had a bicuspid aortic valve, 2 had an associated perimembranous ventricular septal defect, and 1 was being treated for active endocarditis. One patient with a tricuspid aortic valve had a previous aortic valvuloplasty at the time of closure of a subaortic ventricular septal defect. Seven patients had a previous aortic valve commissurotomy. Preoperative aortic annulus size was 22 to 33 mm with 13 being 27 mm or greater. Nineteen of the patients had a significant discrepancy between their aortic annulus diameter and their pulmonary annulus diameters, and the other patient had significant dilatation of the left coronary sinus. One patient required a pulmonary valvuloplasty for a 3-mm fusion of one commissure.
|
). In 2 patients the aortic annulus was decreased in size with two pursestring sutures of 3-0 polypropylene tied external to the aortic annulus in the noncoronary sinus (Fig 2). The aortic annulus was decreased from 28 mm to 24 mm in 1 and from 29 mm to 25 mm in the other. Appropriate size was determined by comparison with the normal expected aortic annulus size based on the patient's body surface area [5]. In 1 of these 2 patients, an associated 7-cm calcified ascending aortic aneurysm was replaced with a 28-mm Dacron graft.
|
|
|
Results |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
The 20 patients have been followed up from 1 month to 5.6 years, with 11 patients followed up for 1 or more years and 7 being followed up for 2 or more years. Postoperative echocardiographic evaluation of autograft function at the patients' most recent assessment has shown no change in autograft function in the 20 patients (Table 2).
|
. Sixteen of the 20 patients had a preoperative Z value greater than 2, with the largest being 5. Four had Z values between 0 and +2; 2 of these patients had an associated ventricular septal defect and the others had significant annulus dysplasia. The indications for use of the external fixation of the aortic annulus in these 4 patients with normal aortic annulus size were concomitant closure of a ventricular septal defect in 2, severe annular dysplasia in 2, and marked discrepancy between the pulmonary and aortic annulus diameters in 1 patient requiring a minor pulmonary valvulotomy before use of this valve as an autograft valve.
|
|
Comment |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
One would anticipate that the long-term results of the Ross procedure in patients with significant aortic pathology, dilatation of the supraannular aorta, or significant dilatation of the aortic annulus would parallel that seen with allograft replacement of the aortic valve. Barratt-Boyes and colleagues [6] found a 40% incidence of moderate or severe aortic insufficiency within 6 years of valve insertion if the aortic annulus or supraannular aorta was dilated. Virdi and associates [7] reported a 28% incidence of early postoperative insufficiency in those patients who required aortic tailoring of the large aortic root at the time of allograft insertion. O'Brien and McGiffin [8] now recommend in patients with a discrepancy between the annulus and sinotubular diameter that allograft replacement be done as a root replacement.
In our early experience with pulmonary autograft replacement of the aortic valve, 4 patients required reoperation for autograft valve insufficiency: 2 at 1 year, 1 at 2 years, and 1 at 5 years after autograft insertion. At the time of autograft insertion, significant abnormality in the aortic annulus was found in 3. At reoperation, there was no macroscopic abnormality of the valve leaflets, and all valves were repaired by appropriate aortic annuloplasty; in 2 a reduction in the sinotubular diameter was required to correct the aortic insufficiency. In view of this experience and the reported results of annulus reinforcement by Dziatkowiak and co-workers [9] with allograft root replacements in patients with annuloaortic ectasia, patients with a significant discrepancy between the aortic annulus and pulmonary valve annulus diameter or with supraannular aortic enlargement have undergone autograft root replacement with external reinforcement and ``fixation'' of the aortic annulus.
Success with operative repair of annular dilatation in our patients with autograft insufficiency using the technique described by Carpentier [10], as well as the excellent late results reported by Chauvaud and associates [11], led to our use of a formal aortic annuloplasty in 2 patients. The first patient was 13 years old and had 4+ aortic insufficiency and an associated 7-cm calcified ascending aortic aneurysm. The Z value of his aortic annulus was +3.6 before autograft replacement of his aortic valve and was reduced to +1.5 by annuloplasty, a size that should allow for significant somatic growth in this patient. The second patient had an aortic annulus of +2.4, which was reduced to +0.3 by annuloplasty. This patient also had significant dilatation of his proximal aorta, but this area was resected and replaced by the autograft root replacement. We plan to cautiously expand the use of this technique in those patients with annular dilatation and significant aortic pathology.
The early results with this group of patients are encouraging. This has allowed us to use the Ross procedure in a group of patients who would not be considered as candidates in some centers [2]. To date, we have not seen evidence of an increase in the size of the aortic annulus after placement of an external reinforcing cuff of either prosthetic material or pericardium. Because of the dense fibrous tissue that forms around Dacron grafts, we prefer a 3-mm strip of woven Dacron graft for the reinforcement. Recently, in patients with marked annular dilatation, we have used an annuloplasty to decrease the size of the aortic annulus before insertion of the autograft valve.
We have been encouraged to use this technique based on its effectiveness in our patients requiring reoperation for autograft insufficiency. Careful long-term follow-up will be needed to assess the efficacy of this modification of the Ross procedure and to clarify whether this modification will support its use in patients with aortic valve disease and significant annuloaortic pathology. This procedure is not recommended in those patients in whom autograft growth is anticipated and should not be used in patients with Marfan's syndrome or other patients suspected of having abnormal fibrillin in the fibrous skeleton of the heart or aortic root.
|
Footnotes |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
Address reprint requests to Dr Elkins, Thoracic Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190.
|
References |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
Related Article
This article has been cited by other articles:
|
|
 |
|
  R. C. Elkins, D. M. Thompson, M. M. Lane, C. C. Elkins, and M. D. Peyton Ross operation: 16-year experience J. Thorac. Cardiovasc. Surg., September 1, 2008; 136(3): 623 - 630. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Chiappini, B. Absil, J. Rubay, P. Noirhomme, J.-C. Funken, R. Verhelst, A. Poncelet, and G. El Khoury The Ross Procedure: Clinical and Echocardiographic Follow-Up in 219 Consecutive Patients Ann. Thorac. Surg., April 1, 2007; 83(4): 1285 - 1289. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Wang, A. Farnsworth, and H. Albrecht Mid-term results of ross procedure: our limited experience. Asian Cardiovasc Thorac Ann, August 1, 2006; 14(4): 289 - 293. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Settepani, A. Kaya, W. J. Morshuis, M. A. Schepens, R. H. Heijmen, and K. M. Dossche The Ross Operation: An Evaluation of a Single Institution's Experience Ann. Thorac. Surg., February 1, 2005; 79(2): 499 - 504. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Alphonso, M. Baghai, K. Dhital, G. Mood, R. Tulloh, C. Austin, and D. Anderson Midterm results of the Ross procedure Eur. J. Cardiothorac. Surg., June 1, 2004; 25(6): 925 - 930. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. M. Roux and N. Saad Modified ross procedure for dysplasic ascending aorta Ann. Thorac. Surg., November 1, 2003; 76(5): 1754 - 1756. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Mavroudis and R. M. Sade The Southern Thoracic Surgical Association 50th anniversary celebration: the impact of STSA pediatric cardiothoracic surgery manuscripts on surgical practice Ann. Thorac. Surg., November 1, 2003; 76(90050): S47 - 67. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. A. Fullerton, J. W. Fredericksen, R. S. Sundaresan, and K. A. Horvath The Ross procedure in adults: intermediate-term results Ann. Thorac. Surg., August 1, 2003; 76(2): 471 - 477. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Ishizaka, E. J. Devaney, S. R. Ramsburgh, T. Suzuki, R. G. Ohye, and E. L. Bove Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure Ann. Thorac. Surg., May 1, 2003; 75(5): 1518 - 1522. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. A. Fox, V. Formanek, A. Friedrich, and S. K. Shernan Intraoperative Echocardiography Card. Surg. Adult, January 1, 2003; 2(2003): 283 - 314. [Full Text]
|
|
|
|
|
|
G. Svensson, O. Aljassim, S.-E. Svensson, O. Bech-Hanssen, and U. Kjellman Anatomical mismatch of the pulmonary autograft in the aortic root may be the cause of early aortic insufficiency after the Ross procedure Eur. J. Cardiothorac. Surg., June 1, 2002; 21(6): 1049 - 1054. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. A. Pigula, J. Paolillo, M. McGrath, S. K. Gandhi, J. L. Myers, B. Rebovich, and R. D. Siewers Aortopulmonary size discrepancy is not a contraindication to the pediatric Ross operation Ann. Thorac. Surg., November 1, 2001; 72(5): 1610 - 1614. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Laudito, M. M. Brook, S. Suleman, M. S. Bleiweis, L. D. Thompson, F. L. Hanley, and V. M. Reddy The Ross procedure in children and young adults: A word of caution J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 147 - 153. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. J. Knott-Craig, R. C. Elkins, K. Santangelo, C. McCue, and M. M. Lane Aortic valve replacement: comparison of late survival between autografts and homografts Ann. Thorac. Surg., May 1, 2000; 69(5): 1327 - 1331. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. G. Svensson, J. Longoria, W. A. Kimmel, and E. Nadolny Management of aortic valve disease during aortic surgery Ann. Thorac. Surg., March 1, 2000; 69(3): 778 - 783. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. M. Dossche, A. B. de la Riviere, W. J. Morshuis, M. A.A.M. Schepens, S. M. Ernst, and J. J. van den Brand Aortic root replacement with the pulmonary autograft: an invariably competent aortic valve? Ann. Thorac. Surg., October 1, 1999; 68(4): 1302 - 1307. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Niwaya, R. C. Elkins, C. J. Knott-Craig, K. Santangelo, M. B. Cannon, and M. M. Lane Normalization of left ventricular dimensions after ross operation with aortic annular reduction Ann. Thorac. Surg., September 1, 1999; 68(3): 812 - 818. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. F. Northrup III and V. R. Kshettry Implantation technique of aortic homograft root: emphasis on matching the host root to the graft Ann. Thorac. Surg., July 1, 1998; 66(1): 280 - 284. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. M. Reddy, D. B. McElhinney, C. K. Phoon, M. M. Brook, and F. L. Hanley Geometric mismatch of pulmonary and aortic anuli in children undergoing the Ross procedure: Implications for surgical management and autograft valve function J. Thorac. Cardiovasc. Surg., June 1, 1998; 115(6): 1255 - 1263. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. H. Schoof, M. G. Hazekamp, G. van Wermeskerken, E. de Heer, J. A. Bruijn, A. Gittenberger-de Groot, and H. A. Huysmans Disproportionate enlargement of the pulmonary autograft in the aortic position in the growing pig J. Thorac. Cardiovasc. Surg., June 1, 1998; 115(6): 1264 - 1268. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. C. Elkins, C. J. Knott-Craig, K. E. Ward, and M. M. Lane The Ross Operation in Children: 10-Year Experience Ann. Thorac. Surg., February 1, 1998; 65(2): 496 - 502. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
