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Ann Thorac Surg 1997;64:482-486
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Ross Procedure With Aortic Root Tailoring for Aortic Valve Replacement in the Pediatric Population

Section of Thoracic Surgery, Pediatric Cardiovascular Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Aortic valve replacement with a pulmonary autograft (Ross procedure) is being applied more commonly in children. Although indications for this procedure have been expanded, the presence of a dilated aortic annulus has remained a relative contraindication. In this condition, the use of an undersized autograft in an enlarged aortic annulus may result in significant aortic regurgitation.

Methods. Among 68 children and young adults undergoing the Ross procedure, 15 (age range, 8 to 24 years) with severe aortic regurgitation or stenosis and an aortic annulus diameter that was at least 2 mm larger than the pulmonary annulus had aortic root tailoring. In this group, the diameter of the aortic annulus measured 26.6 ± 1.3 mm (mean ± standard error of the mean), whereas that of the pulmonary annulus was 22 ± 0.9 mm. The mean annular difference was 4.6 ± 0.7 mm (range, 2 to 12 mm). The aortic annulus was reduced by excising a triangular wedge of tissue posteriorly from the aortic valve annulus at the level of the commissure between the left and noncoronary cusps extending into the anterior leaflet of the mitral valve. The edges were reapproximated over a calibrated dilator to adjust the final size of the aortic annulus to 2 mm smaller than that of the pulmonary autograft. Circumferential felt strips were not used in any patient.

Results. All patients survived and morbidity was limited to one reoperation for bleeding. Doppler echocardiographic examination performed at discharge demonstrated that no patient had more than trace to 1+ aortic regurgitation and none had evidence of aortic stenosis. Over a mean follow-up period of 6.3 ± 1.5 months (range, 1 to 16 months) there has been no late morbidity or mortality and no progression of aortic regurgitation.

Conclusions. Aortic root tailoring further extends the use of the Ross procedure to patients with excessive aortic annular dilation while maintaining the potential for growth, which is particularly important in the pediatric population.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 486.

The use of prosthetic devices for aortic valve replacement in infants and children is associated with numerous short-term and long-term complications and, in most cases, is considered to be palliative [1–4]. The initial description of aortic valve replacement with a pulmonary autograft by Ross [5] in 1967 provided an attractive alternative to these various prostheses. The Ross procedure obviates the need for anticoagulation and provides autologous tissue with the potential to maintain growth [6, 7]. The viability of pulmonary autografts in the aortic position is well established, and the Ross procedure has rapidly become the procedure of choice for aortic valve replacement in the younger population [8]. Although the indications for pulmonary autograft replacement of the aortic valve have been expanding as experience with the procedure has increased, size mismatch has remained a relative contraindication to the procedure, particularly in the presence of a dilated aortic annulus. When the aortic and pulmonary annulus diameters are similar in size, no changes in the implantation technique are required. However, when the aortic annulus diameter exceeds that of the pulmonary valve, significant aortic insufficiency may result after the Ross procedure, which may compromise the long-term outcome [9]. The use of circumferential strips of prosthetic material or pursestring sutures around the aortic annulus to reduce its circumference to a more appropriate size has been described, but these techniques have the potential to limit growth, a disadvantage in young patients [10]. In 1965, Barratt-Boyes [11] reported a technique of reducing the size of the aortic annulus in association with aortic valve replacement with an aortic allograft. This procedure used a noncircumferential removal of tissue posteriorly at the level of the anterior leaflet of the mitral valve. This approach has the obvious advantage of allowing continued growth of the annulus in infants and young children. We report the results of this procedure of aortic root tailoring to more closely approximate the diameters of the aortic annulus and pulmonary autograft in association with the Ross procedure.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Between January 1991 and July 1996, 68 patients underwent pulmonary autograft replacement of the aortic valve (Ross procedure) for aortic stenosis, regurgitation, or both at C. S. Mott Children's Hospital, University of Michigan Medical School. Aortic root tailoring was begun in March 1995, and since that time 15 patients have undergone this modification of the procedure. This technique was selected when the aortic annulus diameter was 2 mm or greater than that of the pulmonary annulus. The patients' ages ranged from 8 to 24 years (mean, 14.2 ± 1.5 years). There were 12 male and 3 female patients. All patients underwent complete preoperative transthoracic Doppler echocardiographic evaluation as well as additional intraoperative transesophageal Doppler echocardiography to measure the aortic and pulmonary annular diameters.

Operation was performed via median sternotomy with cardiopulmonary bypass at a perfusate temperature of 25°C. Myocardial protection was by means of a combination of cold antegrade and retrograde blood cardioplegia with topical hypothermia. After electromechanical arrest of the heart, the pulmonary artery was transected at its bifurcation and the pulmonary valve annulus size was approximated with calibrated dilators before excision of the autograft. The pulmonary autograft was then harvested with a 2- to 3-mm cuff of muscle, care being taken to avoid injury to the underlying left main coronary artery and the septal perforators posteriorly. The final size of the harvested autograft was again measured with calibrated dilators (Fig 1). This size was taken as the largest dilator that could be passed through the explanted autograft without stretching. The autograft was placed in cold saline solution while awaiting implantation. The aorta was then transected approximately 2 to 3 mm above the sinotubular ridge, leaving most of the noncoronary sinus of Valsalva tissue with the distal aorta. The diseased aortic valve was excised and the coronary ostia were removed with buttons of aortic tissue (Fig 2). Once the annular difference was measured, tailoring of the root was begun by excising a triangular wedge of tissue from the aortic valve annulus at the level of the commisure between the left and noncoronary cusps extending into the anterior leaflet of the mitral valve (see Fig 2). The V-shaped defect was then reapproximated over a calibrated dilator, which was adjusted to achieve a final diameter 2 mm less than that of the pulmonary annulus. The edges were reapproximated with interrupted, pledgeted, horizontal mattress polypropylene sutures (see Fig 2, inset). The autograft was then sutured to the tailored aortic root with a continuous polypropylene suture beginning below the origin of the left coronary artery. The coronary arteries were then implanted into the facing sinuses of the autograft. The right ventricular outflow tract was then reconstructed with an appropriately sized cryopreserved pulmonary allograft while the patient was being rewarmed. The distal aortic anastomosis was completed last (Fig 3). Intraoperative transesophageal Doppler echocardiographic examination was used in each patient to assess valvular function of both the aortic and pulmonary valves. All patients underwent an additional complete transthoracic Doppler echocardiographic study before discharge from the hospital.

View larger version (30K): [in this window] [in a new window]   Fig 1. . The autograft is removed as illustrated and sized over a calibrated dilator (inset). The broken line represents the level of transection of the aorta.

View larger version (30K): [in this window] [in a new window]   Fig 2. . The coronary arteries have been excised as buttons in preparation for reimplantation into the autograft. The broken lines show the excision of the aortic annulus to tailor it for acceptance of the pulmonary autograft. The annulus is then sized to a diameter 2 mm smaller than the autograft and the V-shaped area is reapproximated with horizontal mattress sutures (inset).

View larger version (31K): [in this window] [in a new window]   Fig 3. . The pulmonary autograft is sutured into the aortic position with the coronary arteries reimplanted; the right ventricular outflow tract has been reconstructed with an appropriate pulmonary allograft.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Replacement of the aortic valve in infants and children is associated with a number of problems that seriously limit its effectiveness. The currently available devices include mechanical, heterograft, and allograft prostheses, all of which, however, have significant limitations in young patients. These include size mismatch, availability, durability, growth limitation, and thromboembolic complications, which often result in major postoperative morbidity in addition to the need for early and frequent reoperation. In children and young adults who require aortic valve replacement, the Ross procedure has now emerged as the operation of choice because it overcomes nearly all of these limitations. The pulmonary autograft is virtually always available and it provides an autologous, viable tissue valve in the aortic position that maintains the potential to grow. Additionally, it provides freedom from most valve-related complications, including thromboembolism, and therefore obviates the need for long-term anticoagulation in children [7]. Although the cryopreserved allograft used to replace the pulmonary valve is unlikely to provide the same degree of durability as the autograft and reoperation will be required, this limitation is far less serious than repeated aortic valve replacements. The durability of the autograft valve has been documented in the adult patient, but long-term studies are not yet available for infants and younger children [12].

The current preferred technique for the Ross procedure is to insert the valve as a root replacement [13]. This requires close size matching to avoid distortion and postoperative regurgitation. When the aortic annulus is smaller than that of the pulmonary annulus, particularly in association with subaortic stenosis, division of the annulus and septum to enlarge the outflow tract has been shown to be a useful addition to the Ross procedure. Although this situation is more common in children, long-standing aortic regurgitation, particularly after prior intervention on the valve, may result in excessive dilatation of the aortic annulus beyond that of the pulmonary valve. Use of an undersized autograft in an enlarged annulus has been shown to result in aortic regurgitation after the Ross procedure [9]. In the past, this condition was considered a relative contraindication to the Ross procedure [14]. To avoid this problem, however, techniques have been described to reduce the size of the aortic annulus by insertion of a circumferential felt strip or placement of a pursestring suture around the autograft [10]. These techniques are effective in adult patients but have the potential to limit the growth of the annulus and, consequently, are less optimal for use in young children.

This problem was addressed by Barratt-Boyes in association with aortic valve replacement with an aortic allograft [15]. A noncircumferential technique of reducing the aortic annulus by excision of a V-shaped wedge of tissue posteriorly at the level of the anterior leaflet of the mitral valve was shown to be effective in optimizing the size discrepancy between the aortic annulus and the allograft without resulting in mitral valve dysfunction. We began to employ this technique after an examination of our earlier results with the Ross procedure demonstrated significantly more postoperative aortic regurgitation in those patients in whom the aortic valve diameter was at least 2 mm larger than that of the pulmonary annulus [16] (Fig 4). Furthermore, that analysis demonstrated that the most optimal postoperative results were achieved in that group of patients where the difference between the aortic annulus and the pulmonary annulus was -2.3 mm. Therefore, based on these data, we adjusted the native aortic annulus to a final diameter that was approximately 2 mm smaller than that of the autograft to reduce the risk of autograft dilatation and prolapse. This technique has resulted in excellent postoperative valve function. No patient has more than trace to mild regurgitation and none has residual left ventricular outflow tract obstruction. Furthermore, there have been no instances of mitral valve stenosis or regurgitation. This reflects relatively short-term follow-up and will require further long-term surveillance. This technique, which is simple and reproducible, appears suitable for all patients with the possible exception of those with significant calcification in the annulus. Even the extremely dilated aortic annulus is suitable, and this technique has been successfully used for size discrepancies as large as 12 mm in this series.

View larger version (15K): [in this window] [in a new window]   Fig 4. . Aortic regurgitation as a function of the difference of the aortic annulus diameter (AV) and pulmonary annulus diameter (PV). Significant aortic regurgitation was seen only in those patients where the annular difference was 2 mm or greater.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.

Address reprint requests to Dr Bove, Pediatric Cardiovascular Surgery, F7830 Mott Hospital, Box 0223, 1500 E. Medical Center Dr, Ann Arbor, MI 48109.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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