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Ann Thorac Surg 1999;67:1843-1845
© 1999 The Society of Thoracic Surgeons

Ross procedure for ascending aortic replacement

^a Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

Address reprint requests to Dr Elkins, Thoracic Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Patients with aortic valve disease and aneurysm or dilatation of the ascending aorta require both aortic valve replacement and treatment of their ascending aortic disease. In children and young adults, the Ross operation is preferred when the aortic valve requires replacement, but the efficacy of extending this operation to include replacement of the ascending aorta or reduction of the dilated aorta has not been tested.

Methods. We reviewed the medical records of 18 (5.9%) patients with aortic valve disease and an ascending aortic aneurysm and 26 (8.5%) patients with dilation of the ascending aorta, subgroups of 307 patients who had a Ross operation between August 1986 and February 1998. We examined operative and midterm results, including recent echocardiographic assessment of autograft valve function and ability of the autograft root and ascending aortic repair or replacement to maintain normal structural integrity.

Results. There was one operative death (2%) related to a perioperative stroke. Forty-two of 43 survivors have normal autograft valve function, with trace to mild autograft valve insufficiency, and one patient has moderate insufficiency at the most recent echocardiographic evaluation. None of the patients has dilatation of the autograft root or of the replaced or reduced ascending aorta.

Conclusions. Early results with extension of the Ross operation to include replacement of an ascending aortic aneurysm or vertical aortoplasty for reduction of a dilated ascending aorta are excellent, with autograft valve function equal to that seen in similar patients without ascending aortic disease.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Ascending aortic aneurysm or dilatation of the ascending aorta is seen in 5% to 15% of patients with aortic valve disease [1]. Older patients are frequently treated by replacing the aortic valve and the ascending aorta with a valved conduit; for patients with a known genetic basis for their aortic and valvar disease this remains the standard of care. The use of a prosthetic valved conduit commits the patient to a lifetime of anticoagulation with the persistent risk of thromboembolism and of anticoagulant-related hemorrhage. In children and young adults, that treatment carries a significant hazard over a lifetime, and requires a significant alteration in lifestyle. At the University of Oklahoma, we use the Ross operation for replacement of the diseased aortic valve. In patients with an aortic aneurysm, the ascending aorta is replaced with a knitted Dacron graft, and in patients with dilatation of the ascending aorta, a vertical aortoplasty is used to reduce the diameter of the ascending aorta. This avoids the need for anticoagulation and allows these patients to have a more normal lifestyle.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
The medical records of the 307 patients who had the Ross operation between August 1986 and February 1998 were reviewed, and 18 (5.9%) of the cases included repair of an ascending aortic aneurysm. An additional 26 (8.5%) had significant ascending aortic dilatation requiring a vertical aortoplasty. Preoperative echocardiograms and, when available, contrast angiography or magnetic resonance imaging were used with the operative findings to assess ascending aortic size, valve pathology, and additional distal aortic pathology. The histologic specimens were reviewed to assess evidence for a genetic basis of the patient’s disease.

Contact for clinical evaluation was made with all patients within 6 months of the closing date of this study, and echocardiographic evaluation of autograft valve function and ascending aorta size was obtained for all patients within 1 year of closure.

Age ranged from 7 to 51 years (median, 31 years) in the aneurysm group, and 3 to 60 years (median, 36 years) in the dilatation group. Seven of the 18 patients with aortic aneurysms (39%) were female, and 5 of the patients with aortic dilatation (19%) were female. Aortic valve insufficiency was the predominant abnormality in 10 patients, 7 had aortic stenosis, 26 had aortic stenosis and aortic insufficiency, and 1 patient had an ascending aortic aneurysm after aortic valve replacement with a prosthetic valve. Aortic valve morphology was bicuspid in 34, tricuspid in 3, and unicuspid in 7 patients. Fourteen patients had required previous aortic valve operations, and 4 of them had previous aortic valve replacement. Coarctation had been repaired in 4 patients, and 1 patient had had a patent ductus closed as a child.

Before acceptance of these patients for a Ross operation, they were screened carefully by detailed medical and family history for evidence suggestive of a connective tissue disorder that might affect their pulmonary valve. No genetic testing was done. One patient with an ascending aortic aneurysm was known to have Turner’s syndrome; however, we have not considered this a contraindication for a Ross operation.

Ascending aortic aneurysm size ranged from 3 cm (in a 7-year-old child) to 9.5 cm, with a median of 6 cm in the patients who had an interposition Dacron graft replacement of their ascending aorta. In the patients treated with a vertical aortoplasty, the ascending aortic diameter was 3.3 to 5.5 cm, with a median of 4 cm. Twenty-four patients had significant dilatation of the aortic valve annulus and had an aortic valve annuloplasty and fixation of the aortic annulus with an external Dacron cuff, using a technique previously described [2]. Thirteen additional patients had the aortic valve annulus supported with a pericardial strip (n = 8) or a Dacron cuff (n = 5). Forty-two patients had the Ross operation as a root replacement, and 2 had an inclusion cylinder [3].

Follow-up is complete for all patients, and ranges from 0.3 to 2.2 years in the aortic aneurysm group and 0.3 to 2.5 years in the aortic dilatation group. Total follow-up time is 43 patient-years.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There was one operative death, in a patient with an aortic aneurysm, related to a perioperative stroke. Two patients required permanent pacemaker implantation, on the sixth and ninth postoperative days. Echocardiographic assessment of autograft valve function in the early postoperative period was excellent, with trace or mild insufficiency in all patients.

One patient required reoperation for autograft insufficiency. This patient, who had aortic stenosis and a coarctation of the aorta, previously had a balloon valvuloplasty of the coarctation and of the aortic valve at age 7 years. At age 20, he had a Ross operation with replacement of his 6-cm aortic aneurysm with a 24-mm Dacron graft. His aortic annulus was 23 mm, which is normal for his body surface area, and the proximal suture line was not supported with an external cuff. Two months postoperatively, annular dilatation developed with moderate autograft insufficiency and recurrent symptoms. At reoperation, the aortic annulus was reduced from 29 mm to 22 mm with restoration of autograft valve function to mild insufficiency.

Autograft valve function as assessed by the most recent echocardiographic evaluation (within 1 year of closure) demonstrates retained normal function in 42 of the 43 survivors. One patient has moderate autograft valve insufficiency that developed shortly after a significant motor vehicle accident with sternal injury. Enlargement of the ascending aorta has not been demonstrated by postoperative transthoracic echocardiography in the patients with a reduction vertical aortoplasty. Measurement of the aortic root diameter, a diameter that corresponds to the maximal sinus diameter of the autograft valve, was greater than the upper limit for normal aortic valve sinus diameter (35 mm) in 13 of 43 patients. Although these patients have a sinus diameter that approximates 40 mm, neither progressive change in the sinus diameter nor autograft valve dysfunction has been seen. Actuarial freedom from moderate aortic insufficiency is similar in patients with ascending aortic replacement or ascending aortic repair to all other patients who had a Ross operation at our institution (Fig 1).

View larger version (22K): [in this window] [in a new window]   Fig 1. Actuarial freedom from moderate aortic insufficiency as assessed by echocardiography in patients who had a Ross operation with and without repair or replacement of the ascending aorta.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

The presence of an abnormal aortic wall in patients with coarctation of the aorta and a bicuspid aortic valve has been suggested by McKusick [10], and others have noted an increased incidence of ascending aortic aneurysm or dilatation in patients with aortic insufficiency and a bicuspid aortic valve [11]. Histologic examination of aortic tissues has shown that these conditions may be formes frustes of Marfan syndrome, primarily based on the finding of cystic medial necrosis. The pathologic finding of cystic medial necrosis is not necessarily indicative of a generalized connective tissue disorder because it is found in older patients who have no gross abnormality of the aorta [12]. Patients with a stenotic bicuspid aortic valve and dilatation of the ascending aorta or aneurysm formation are at an increased risk for dissection, and surgeons have suggested replacement of the ascending aorta at the time of aortic valve replacement. As there is no known genetic basis for the combination of bicuspid aortic valve disease and ascending aortic dilatation and there is no evidence of a generalized elastin or fibrillin disorder that might also involve the pulmonary artery and valve, we used the Ross operation for aortic replacement in patients thought to have aneurysmal changes in the ascending aorta and a reduction aortoplasty in patients with a dilated ascending aorta and a normal-appearing aortic wall.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Carrel T., von Segesser L., Jenni R., et al. Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach. Eur J Cardiothorac Surg 1991;5:137-143.[Abstract]
2. Elkins R.C. The Ross operation in patients with dilation of the aortic annulus and of the ascending aorta. In: Cox J.L., Sundt T.M., III, eds. Operative techniques in cardiac & thoracic surgery: a comparative atlas. Philadelphia, Pennsylvania: W.B. Saunders Co, 1997:331.
3. Elkins R.C., Santangelo K., Stelzer P., et al. Pulmonary autograft replacement of the aortic valve: an evolution of technique. J Card Surg 1992;7:108-116.[Medline]
4. Larson E.W., Edwards W.D. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 1984;53:849-855.[Medline]
5. Gore I. Dissecting aneurysms of the aorta in persons under forty years of age. AMA Arch Pathol 1953;55:1-13.[Medline]
6. Fenoglio J.J., Jr, McAllister H.A., Jr, DeCastro C.M., et al. Congenital bicuspid aortic valve after age 20. Am J Cardiol 1977;39:164-169.[Medline]
7. Lindsay J., Jr Coarctation of the aorta, bicuspid aortic valve and abnormal ascending aortic wall. Am J Cardiol 1988;61:182-184.[Medline]
8. Gillinov A.M., Zehr K.J., Redmond J.M., et al. Cardiac operations in children with Marfan’s syndrome: indications and results. Ann Thorac Surg 1997;64:1140-1145.[Abstract/Free Full Text]
9. David T.E., Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617-621.[Abstract]
10. McKusick V.A. Association of congenital bicuspid aortic valve and Erdheim’s cystic medial necrosis. Lancet 1972;1:1026-1027.[Medline]
11. Epperlein S., Mohr-Kahaly S., Erbel R., et al. Aorta and aortic valve morphologies predisposing to aortic dissection. Eur Heart J 1994;15:1520-1527.[Abstract/Free Full Text]
12. Schlatmann T.J.M., Becker A.E. Histologic changes in the normal aging aorta: implications for dissecting aortic aneurysm. Am J Cardiol 1977;39:13-20.[Medline]

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