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Ann Thorac Surg 1996;62:450-455
© 1996 The Society of Thoracic Surgeons
Section of Thoracic and Cardiovascular Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Abstract |
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Methods. One hundred ninety-five operative survivors of the Ross operation (August 1986 through December 1995) were reviewed for operative pathology and factors associated with reoperation or valve dysfunction.
Results. Actuarial freedom from reoperation (autograft or homograft) is 89% ± 3% at 5 years, 92% ± 3% for the autograft alone. Early autograft valve failures (<6 months) were due to technical error in 2 patients and persistent endocarditis in 1. Late autograft valve failure (1 to 6.2 years) was due to aortic annulus dilatation in 5 patients, bacterial endocarditis in 1, and valve degeneration in 2. Six autograft valves were replaced and five were repaired. Five patients required reoperation for pulmonary homograft stenosis (1 to 5.4 years) involving obstruction of the conduit distal to the pulmonary valve.
Conclusions. Pulmonary autograft replacement of the aortic valve has a low incidence of reoperation for autograft dysfunction or homograft obstruction. Autograft dysfunction can be corrected by autograft repair in patients with central insufficiency and aortic annular dilatation.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Pulmonary autograft replacement of the aortic valve, introduced in 1967 by Ross [1], has had increasing acceptance by patients and physicians. Avoidance of anticoagulation, freedom from the risk of thromboembolism, and growth of the autograft proportional to the somatic growth of the child or young adult are features that commend this operation. The hemodynamic performance of the pulmonary autograft valve is similar to that of the native normal aortic valve due to its similar anatomy and size. These very attractive features are counterbalanced by the increased technical difficulty of the operation and the risk of early and late valve failure requiring reoperation for either the autograft valve or the homograft right ventricular outflow tract reconstruction.
Ross and associates [2] have reported the late results in 339 autograft patients, with freedom from autograft replacement of 85% at 20 years and a freedom from all valve-related events of 70% at 20 years. In recent years the Ross operation has increasingly used implantation of the autograft as a root replacement, and there is almost universal acceptance of the pulmonary homograft for right ventricular outflow tract reconstruction [3, 4]. Most of these homografts have been cryopreserved and have some degree of viability of donor cells, which may affect the fate of the homograft [5]. To assess a more recent experience, one in which multiple operative techniques were performed, and to identify possible technical and patient-related factors that might be related to autograft failure, we reviewed our experience since 1986.
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Material and Methods |
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The outcomes evaluated were reoperation of autograft or homograft valve and the development of consistent 2+ autograft valve insufficiency. Patient characteristics and operative factors evaluated for possible association with outcomes included age, sex, autograft implantation technique, use of cuff reinforcement of annulus, previous median sternotomy, concomitant procedures, preoperative presence of bacterial endocarditis, year of operation, intraoperative measurement of aortic annulus size, and preoperative diagnosis of aortic insufficiency or aortic stenosis.
Categoric variables were tested for association with outcomes using maximum-likelihood 
2 tests. Ordered categoric variables were evaluated using Mantel-Hanzel 2, and continuous variables were tested using univariate logistic regression and maximum-likelihood 2. Multiple logistic regression was used to develop multivariable models. Forward stepwise selection of variables was used, with a criterion of p less than 0.10 for entry into the model. SAS software version 6.10 (SAS Institute Inc, Cary, NC) was used for all statistical tests. The degree to which the logistic regression model discriminated between positive and negative outcomes was estimated by the area under the receiver operating characteristic curve [6]. The statistic ranges from 0.5 for a model with no discriminating ability to 1.0 for a model that discriminates perfectly. Actuarial analysis was accomplished using Kaplan-Meier estimation methods, and p values for differences between distributions were obtained by log-rank testing.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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), with freedom from reoperation on the autograft valve of 92% ± 3% at 5 years (Fig 2) and freedom from reoperation on the homograft reconstruction of the right ventricular outflow tract of 95% ± 2% at 5 years (Fig 3).
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AUTOGRAFT VALVE.
Autograft valve dysfunction leading to early reoperation in this series was due to persistent endocarditis in 1 patient and technical errors in 2. In 1, malalignment of the autograft valve commissures in a scalloped subcoronary implant led to leaflet prolapse and progressive autograft insufficiency. This patient underwent the second Ross operation in this series, and this technical error was part of the learning curve associated with this operation. In the other, pulmonary autograft root implantation was performed in a patient with an ascending aortic aneurysm, bicuspid aortic valve with severe aortic insufficiency and mild aortic stenosis, and a 23-mm aortic annulus. The intraoperative echocardiogram demonstrated 1 to 2+ autograft insufficiency. This insufficiency progressed, and by 2 months after the operation, the patient had 3 to 4+ autograft insufficiency and aortic annulus dilatation to 27 mm. A reduction annuloplasty to 20 mm and commissural annuloplasty was successful in reestablishing autograft function with minimal autograft insufficiency. The intraoperative echocardiographic detection of more than trace to 1+ autograft insufficiency after an autograft root replacement is highly unusual, and failure to address this probably contributed to the need for early reoperation in this patient.
Late autograft reoperation (more than 1 year after operation) occurred in 8 patients. In 3, autograft dysfunction leading to reoperation was related to patient factors and operative technique did not appear to play a role. Valve dysfunction was associated with bacterial endocarditis in 1, with systemic lupus erythematosus in 1, and with prolapse of the right coronary leaflet with adherence to a ventricular septal defect patch in the other. Two of these valves were inserted as inclusion cylinders and one as a root replacement. In the remaining 5 patients, a combination of operative and patient factors appear to be related to the autograft failure. Three patients had significant aortic annulus dilatation (aortic annulus diameter Z value greater than +2) and ascending aortic dilatation before autograft insertion. In 1 the autograft was inserted as a scalloped subcoronary implant, in 1 as an inclusion cylinder, and in the other a root replacement was performed. Intraoperative echocardiography demonstrated 1 to 2+ autograft insufficiency. Follow-up evaluation showed progressive aortic insufficiency, and reoperation was required at 2.1, 4.4 and 5.4 years after Ross operation. In 2 patients the autograft was repaired, and in the other it was subsequently replaced after a failed repair. In light of this and more recent experience, these patients would have a reduction annuloplasty of their aortic annulus, fixation of the size of their aortic annulus, and an aortoplasty at the time of autograft replacement of their aortic valve at our institution [7].
Two patients had bicuspid aortic valve disease with aortic stenosis and only 1+ aortic insufficiency. Their ascending aortas appeared normal at the time of autograft insertion. The autografts were inserted as an inclusion cylinder in 1 and as a root replacement in 1. Autograft insufficiency was thought to be trace or mild by intraoperative echocardiography. Reoperation for progressive autograft insufficiency was required at 1 and 1.4 years after Ross operation. At the time of reoperation, aortic annular and sinotubular ridge dilatation was identified in 1 and only aortic annular dilatation in the other. Mild leaflet thickening was also noted but no evidence of leaflet thinning or leaflet perforation. Successful repair of these two valves was accomplished by reduction annuloplasty and insertion of a Dacron graft to decrease the circumference of the sinotubular junction in 1. The possible role of operative technique of autograft insertion in contributing to the late autograft dysfunction in these 2 patients cannot be determined. Certainly, malalignment of the commissures in the inclusion cylinder implants may have contributed to the autograft failure; however, evidence of leaflet prolapse was not seen at reoperation or by echocardiography. The relatively early failure of the root replacement in a patient thought to have a normal ascending aorta and aortic annulus size at the time of autograft insertion is difficult to understand, particularly in view of the excellent autograft function seen in most patients with an autograft root replacement.
Preoperative assessment of the pulmonary valve before autograft translocation has been by echocardiography in all patients and by careful visual inspection at the time of operation. We have not performed a Ross operation in those patients with a bicuspid pulmonary valve, significant leaflet fenestrations, or other abnormality of the pulmonary leaflets or sinuses. Preoperative echocardiographic finding of more than trace pulmonary insufficiency would alert us to carefully evaluate the suitability of this valve. None of the autograft valves requiring reoperation were noted to have significant abnormality before the Ross operation.
In patients with aortic annular dilatation and sinotubular dilatation associated with central autograft valve insufficiency, operative repair has been accomplished with a reduction annuloplasty as described by Carpentier [8]. Two pursestring sutures are placed at the autograft annulus at the nadir of the coronary sinuses and below the annulus in the interleaflet triangles and tied over a Teflon felt pledget in the noncoronary sinus [7]. Additional sutures may be necessary at individual commissures if leaflet prolapse must be repaired, and we use the technique described by Cabrol and associates [9].
STATISTICAL ANALYSIS.
Univariate analysis for operative and patient-related factors for outcome defined as reoperation on the autograft valve identified no variables that had a p value less than 0.05. For p less than 0.10, univariate associations with implantation technique and year of operation were seen (Table 1). Multiple logistic regression analysis for this outcome identified only implantation technique (root replacement, inclusion cylinder, scalloped subcoronary) with a p value of 0.069. Year of operation was not significant (p = 0.35) after entry of implantation technique, probably because the root replacement technique was introduced later than scalloped subcoronary technique and its use has steadily increased.
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). A significant multivariate association was found for a combination of three of these variables: preoperative diagnosis of aortic stenosis, implantation technique (intraaortic versus root replacement), and previous median sternotomy (Table 3). This suggests that patients with aortic stenosis as part of the operative indication are at a lower risk of autograft reoperation or the development of echocardiographically demonstrated aortic insufficiency than those patients with aortic insufficiency as their valve lesion. Also, patients having their autograft aortic valve replacement as a root replacement are at a lower risk for the same outcome. When the apparent lower risk of patients with previous median sternotomy is examined closely, interaction with the diagnosis of aortic stenosis is found (Fig 4). The "protective" effect of previous median sternotomy is present only for patients with aortic stenosis and has no obvious effect on the risk for aortic insufficiency patients. The area under the receiver operating characteristic curve for this model is 0.77.
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Comment |
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The surgeon's ability to translocate the pulmonary valve as an anatomic unit or in a manner such that normal leaflet coaptation is maintained affects the early and late occurrence of valve dysfunction. The autograft root replacement used by Gerosa and associates [13] and Stelzer and colleagues [14] ensures insertion of the autograft valve as an anatomic unit and should have a decreased incidence of failure. Logistic regression analysis of outcome of our patients did not find a significant difference between operative technique at p less than 0.05 until the definition of outcome was extended to include 2+ or more aortic insufficiency, an outcome that may be predictive of reoperation. In two of the three root replacements, intraoperative assessment of aortic annulus size or anatomy of the left ventricular outflow tract would not have predicted relatively early valve failure. In 1 patient, annulus reduction and fixation was probably indicated at the time of the original operation, and this could have eliminated or delayed valve failure in this patient. Two additional patients in this series, one with a scalloped subcoronary and one with an inclusion cylinder implant, had annular dilatation at the time of operative insertion of their autograft, and annular reduction and fixation were probably also indicated in these.
With the increase in the number of Ross operations and the number of surgeons performing these procedures, the autograft root replacement is the most popular and appears to have a reduced incidence of early failure (Oury JH, personal communication, 1996). Logistic regression analysis in our patients demonstrates a lower risk of autograft reoperation for the patients with root replacements at a p value less than 0.1. When reoperation and autograft insufficiency of 2+ or more are combined as an outcome, the p value became less than 0.05 for both univariate and multivariate logistic regression analysis. Although echocardiographic demonstration of 2+ autograft insufficiency is not associated with symptoms and may not lead to reoperation, it appears to be part of a larger pattern of the spectrum of outcomes that may be predictive of reoperation at the extreme end of the spectrum. To date, only 8 years of follow-up is available in patients who have had an autograft root replacement, and if our data can be confirmed and this technique proves to be as durable as the intraaortic implant, this enthusiasm for the root replacement will be justified.
The demonstration of the increased risk for autograft reoperation or the development of autograft valve insufficiency in patients with the preoperative diagnosis of aortic insufficiency has confirmed a clinical impression that aortic annular dilatation and central autograft insufficiency are likely to develop in these patients and require autograft reoperation. Although intraoperative aortic annulus size was not a significant predictor of outcome, careful review of the patients in our series in whom 2 to 3+ autograft insufficiency has developed but who have not required reoperation leads us to recommend an aortic annulus reduction and fixation of the annulus size at the time of the Ross operation for patients with dilated annulus.
Reconstruction of the right ventricular outflow tract is usually accomplished with an allograft valve, and most surgeons use a pulmonary homograft. This choice has been confirmed by the reports by Bando and associates [15] and Clarke and Bishop [16] that have shown a decreased failure rate in cryopreserved pulmonary homografts when compared with aortic homografts. Accelerated degeneration has been seen in patients less than 1 year of age [16] and occasionally in adult autograft patients [17]. This accelerated degeneration may be related to host immunologic response, but this is unproven. Most of the early failures of the homografts used in patients having a Ross operation are in cryopreserved allografts, and Ross [18] has not seen accelerated degeneration in patients reconstructed with a cadaveric, antibiotic-sterilized homograft. In the patient in whom homograft failure develops, replacement is a relatively uncomplicated procedure, and replacement with a pulmonary homograft has provided a satisfactory solution. It is apparent that a rare patient will have another episode of accelerated degeneration; in this situation the surgeon probably should replace the homograft with a cadaveric, nonviable valve or, if a cryopreserved homograft is used, the patient should be treated with immunosuppressives.
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Footnotes |
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Address reprint requests to Dr Elkins, Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190.
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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K. Niwaya, C. J. Knott-Craig, M. M. Lane, K. Chandrasekaren, E. D. Overholt, and R. C. Elkins CRYOPRESERVED HOMOGRAFT VALVES IN THE PULMONARY POSITION: RISK ANALYSIS FOR INTERMEDIATE-TERM FAILURE J. Thorac. Cardiovasc. Surg., January 1, 1999; 117(1): 141 - 147. [Abstract] [Full Text] [PDF]
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J. Jaggers, J. K. Harrison, T. M. Bashore, R. D. Davis, D. D. Glower, and R. M. Ungerleider The Ross Procedure: Shorter Hospital Stay, Decreased Morbidity, and Cost Effective Ann. Thorac. Surg., June 1, 1998; 65(6): 1553 - 1557. [Abstract] [Full Text] [PDF]
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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]
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A. Prat, J. Saez de Ibarra, A. Vincentelli, C. Decoene, C. Savoye, and Y. Goffin Late autograft and homograft endocarditis after the ross operation J. Thorac. Cardiovasc. Surg., June 1, 1998; 115(6): 1388 - 1388. [Full Text] [PDF]
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P. Stelzer, S. Weinrauch, and R. F. Tranbaugh Ten years of experience with the modified Ross procedure J. Thorac. Cardiovasc. Surg., May 1, 1998; 115(5): 1091 - 1095. [Abstract] [Full Text] [PDF]
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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]
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J. C. Chambers, J. Somerville, S. Stone, and D. N. Ross Pulmonary Autograft Procedure for Aortic Valve Disease : Long-term Results of the Pioneer Series Circulation, October 7, 1997; 96(7): 2206 - 2214. [Abstract] [Full Text]
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 J. M. Matloff and A. Chaux Cardiothoracic Surgery JAMA, June 18, 1997; 277(23): 1843 - 1845. [PDF]
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