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Ann Thorac Surg 1999;68:1403-1406
© 1999 The Society of Thoracic Surgeons
a The International Heart Institute of Montana, Missoula, Montana, USA
Address reprint requests to Dr Oury, The International Heart Institute of Montana, 554 West Broadway, Missoula, MT 59801
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Abstract |
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Introduction |
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The Ross procedure has also been expanded to neonates and infants with complex aortic root pathology with excellent results in both the immediate and midterm periods [4]. However, its application in complicated acquired adult aortic root conditions has had less appreciation and evaluation.
It is the purpose of this report to present the application of the Ross procedure in a patient with extensive aortic root pathology, both subannular and supraannular extending to the transverse arch. The patient had undergone two previous aortic root procedures and presented for his third procedure at age 21.
A 21-year-old man presented with extensive aortic root pathology after two previous procedures at ages 5 and 15 years. He had originally undergone aortic valvuloplasty and supraannular patch reconstruction for congenital aortic valvular and supravalvular stenosis. At age 15 years he underwent reoperation at which time his aortic valve was replaced with a 23-mm St. Jude mechanical valve (St. Jude Medical, St. Paul, MN). To deal with the supravalvular problem, a graft was placed "... at the level of the commissures and somewhat below the coronary ostia, which were large." Because of significant intraoperative bleeding through the graft material, the previous operative note stated that it was necessary to place a Teflon felt band over the majority of the ascending aortic Dacron graft.
The patient’s postoperative course after this second operation was uncomplicated. However, while on anticoagulant therapy he experienced a spontaneous intraspinal bleed leading to a transient paraplegia that required emergency incision and drainage to restore normal neurologic function. At that time, his warfarin was discontinued. He had remained on aspirin until the time of the present procedure.
Symptoms of exercise-induced fatigability had also developed. Transthoracic echocardiography demonstrated a 55-mm Hg mean resting gradient across the mechanical prosthesis and the subaortic area, with the suggestion of a subannular narrowing or membrane by echocardiography. These findings prompted surgical consultation and operation.
At operation, dense adhesions were encountered between the entire ascending aorta with the external Teflon felt wrap and surrounding structures. Standard bicaval cannulation technique was used together with femoral artery cannulation for cardiopulmonary bypass. Systemic hypothermia to 26°C was used, with both antegrade and retrograde blood cardioplegia for myocardial protection. An insulating pad was placed between the heart and the posterior mediastinal structures. With satisfactory exposure obtained, the aorta was cross-clamped and alternating antegrade and retrograde myocardial protection was begun. Topical iced saline and continuous monitoring of the myocardial temperature were used with the goal of maintaining myocardial temperatures below 10°C. Cold blood cardioplegia was administered every 20 minutes, antegrade or retrograde or by direct coronary cannulation.
The existing ascending aortic graft was first removed along with the anterior portion of the right pulmonary artery, which was imbedded in the Teflon felt posteriorly. The pulmonary autograft root was next harvested in the manner originally described by Ross [1]. As its length was not sufficient to reach the distal ascending aorta/transverse arch, it was necessary to extend the pulmonary autograft using a 24-mm Dacron conduit (Hemashield, Meadox Medical, Oakland, NJ), (Fig 1). The patient was cooled to 17°C and under a 17-minute period of circulatory arrest, an open distal anastomosis was constructed between the distal aorta and the Dacron graft.
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Reconstruction of the right ventricular outflow tract (RVOT) and the right pulmonary artery was then accomplished using a pulmonary homograft (Cyrolife, Inc, Kennesaw, GA) with attached branch pulmonary arteries. The distal portion of the homograft pulmonary artery was used as a patch to reconstruct the excised anterior portion of the native right pulmonary artery. With the distal pulmonary homograft and pulmonary artery reconstruction secure, the end-to-end anastomosis between the pulmonary autograft and the distal Dacron graft was performed. The proximal pulmonary homograft was then anastomosed to the RVOT in the usual fashion.
Aortic cross-clamp time was 263 minutes. Sinus rhythm returned within 5 minutes after removal of the aortic cross-clamp. After 30 minutes of rewarming and stabilization, the patient was easily weaned from cardiopulmonary bypass. After bypass transesophageal echocardiogram demonstrated a competent pulmonary autograft from the left ventricular outflow tract (LVOT) to the ascending aorta with a physiologic gradient (< 5 mm Hg). Normal left ventricular function was also documented by transesophageal echocardiogram.
The patient’s postoperative course was uneventful. He was extubated within 12 hours, moved from the intensive care unit within 18 hours, and discharged on his fifth postoperative day.
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Comment |
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The expansion of this procedure for the neonate and infant born with complex aortic root pathology has evolved in the past decade beginning with the report of Drs Dewan and Oswalt submitted in 1994 to the Ross registry of a 1-day-old infant undergoing the Ross procedure (J. D. Oswalt and S. J. Dewan, personal communication). Hanley’s group [6] in San Francisco has reported excellent early and mid-term results in this age group, adding significantly to the surgeon’s repertoire when dealing with complex aortic root pathology by using the Ross procedure or additional LVOT widening procedures, formerly amenable only to the standard Konno procedure. With the Ross/Konno operation, they have reported complete relief of outflow tract obstruction, with excellent short- and midterm results.
When dealing with the adult patient, however, whose original pathology involved complex aortic root reconstruction in infancy or childhood, the basic components of this operation leading to a successful outcome using the Ross procedure have been less well-appreciated and applied.
Principles leading to a successful outcome in these acquired or iatrogenic forms of aortic root pathology, are summarized as follows: (1) optimum exposure and uniform meticulous myocardial protection anticipating a prolonged period of ischemic arrest; (2) placement of an architecturally perfect pulmonary homograft, which also, because of the marked distortion of the aortic root encountered in these situations, requires root replacement; and (3) accurate reconstruction of the RVOT and pulmonary artery using a pulmonary homograft. The operative sequence followed in this case emphasized these basic principles and allowed excellent exposure, good myocardial protection, and secure hemostasis of all suture lines. All the techniques used in this procedure are part of current standard cardiovascular teaching [7]. However, the sequence involved in these techniques is worth noting as it allows a methodical and unhurried approach to this complex problem and achievement of an optimal outcome.
The perioperative risks of this procedure must be weighed against other suitable alternatives including aortic homograft root replacement, unstented porcine xenograft root replacement, and composite mechanical valve conduit alternatives. In this setting, however, each of the alternatives requires a fairly similar approach in terms of myocardial protection and prolonged ischemic time owing to the complexity of the aortic root pathology encountered and the necessity of removing the entire aortic root and prosthetic valve. They also individually do not address the LVOT obstruction that was a component of the clinical presentation of this patient. As demonstrated with the Ross/Konno procedure, this last problem is easily solved by use of the pulmonary graft with attached right ventricular free wall muscle, allowing widening of the LVOT as necessary.
The long-term durability of the pulmonary autograft in the aortic position has been documented both experimentally and clinically [8, 9]. The hemodynamic performance of the pulmonary autograft is also identical to its normal counterpart and certainly superior to other mechanical or biologic alternatives [10]. The freedom from complications related to anticoagulation is also of obvious importance in this particular case as the patient had previously documented warfarin-related complications. The issue of long-term durability of the pulmonary autograft has been raised in terms of its use in young adults. Data compiled by the Ross registry document a greater than 80% 25-year survival with the pulmonary autograft in the aortic position and similar statistics for the pulmonary homograft used to reconstruct the RVOT [11].
In conclusion, the Ross procedure as performed in a patient with complex aortic valve pathology provided an optimally suited solution for this problem. The pulmonary autograft was easily adapted to this complex LVOT and aortic root pathology and provided a satisfactory clinical result. The perioperative risk of this procedure, primarily the prolonged cross-clamp time, must be weighed against the long-term performance of other alternatives.
Consideration must be tempered by the realization that an individual approach to the patient is dependent on the experience of the surgeon performing such repairs. However, in experienced hands, the Ross procedure is feasible and provides significant immediate and long-term advantages in selected patients with complex aortic root pathology.
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This article has been cited by other articles:
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  E. Lansac, H.S. Lim, Y. Shomura, K.H. Lim, W. Goetz, N.T. Rice, C. Acar, and C.M.G. Duran Aortic and pulmonary root: are their dynamics similar? Eur. J. Cardiothorac. Surg., February 1, 2002; 21(2): 268 - 275. [Abstract] [Full Text] [PDF]
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