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Ann Thorac Surg 1997;64:663-664
© 1997 The Society of Thoracic Surgeons
DR GEORGE R. DAICOFF (St. Petersburg, FL): I thank the Association for the opportunity to discuss this paper and Dr Prager for faxing me his manuscript. This is a wonderful electronic age we live in. I have three comments: (1) sometimes more is better; (2) the evolution of this operation; and (3) sometimes less is more.
Regarding the first, we too started the same way you did with the, I call it the Ross I procedure, the subcoronary scalloped, freehand, whatever you want to call it, procedure for the aortic valve replacement and homograft; this was about 1986. And then, fortuitously, a patient came in who required a root replacement as well. It was a young patient. We decided to put the homograft in as a root replacement and it was a wonderful operation; it worked very well. For a couple of years we were doing one operation or the other, depending on how we felt that particular day. And finally, after looking at some of these early operations showing some leakage, as yours did, we gave up the subcoronary position operation approximately in 1990 and have persisted with the root replacements.
And then, because of our interest in the kids, we wanted an operation that perhaps would last longer. We had Ron Elkins come and show us how to do the Ross II procedure, which is the pulmonary autograft. Therefore, we ended up with a bivalve replacement and have continued to do the Ross procedure whenever applicable.
Last year we did five and only one homograft, and that would have been a Ross except the pulmonary was unacceptable. So we have evolved one more step than you have and we think that more is better. And this I think is the evolution that will take place.
It is not an answer, though, because some of these valves are leaking. Some of these root replacements are 10 years old and they are showing 1+ leakage in some of them. None are severe enough to get concerned, but they may in the future.
For example, we saw a 10-year-old girl with Marfan's syndrome and a dilated root, and the cardiologist came and said, "Her aortic valve is not leaking; what can you do about this?" I was reluctant to put in a valved conduit. I did not like any of the options. I was not really thrilled with the idea of doing Tirone David's operation; although it is a wonderful operation, I think it requires a little bit of expertise and experience to do his operation in a predictable manner to preserve the aortic valve.
Therefore, I chose to do something else. Bcause the aortic valve was not leaking, I decided to stabilize the aortic valve. We took echocardiographic measurements of the circumference of the aortic annulus and the circumference at the sinotubular ridge and derived the depth from the two measurements and decided that this would be probably the best way to do this operation. It really came outside of the parameters that Tirone David measured, but it worked for this girl. So we customized it. We could not use a tubular graft under these circumstances.
I transected the aorta above the sinotubular ridge, slid the Dacron patch down, and sewed it into the aortic annulus from the inside using multiple stitches. That fixed the aortic annulus so that it would prevent annular dilatation to some degree. The top suture line incorporated the graft and the transected aorta. Therefore, we have one suture line instead of four. It is a simple operation; it worked very nicely.
This girl came back yearly, and her last echocardiogram shows that where the aortic valve comes together (the annulus is now fixed in this position) has not changed one bit in 3 years. And she has grown from 1.75 to 1.88 m and has shown no aortic regurgitation.
Therefore, we think that maybe there are a few instances where less is more, and this is just one more operation you might consider in the future.
Related Article
Ann. Thorac. Surg. 1997 64: 659-663.
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