Ann Thorac Surg 1999;68:1842-1843
© 1999 The Society of Thoracic Surgeons
Case Reports
Aneurysms complicating pulmonary autograft procedure for aortic valve replacement
Maie S. Shahid, MDa,
Zohair Al-Halees, FRCSa,
Shahid M. Khan, MDa,
Frans A.A. Pieters, MDa
a Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Address reprint requests to Dr Shahid, Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, PO Box 3354, MBC 16, Riyadh 11211, Saudi Arabia
e-mail: maie{at}kfshrc.edu.sa
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Abstract
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Aneurysm formation in the left ventricular outflow tract related to the proximal end of the pulmonary autograft after the Ross procedure was present in 2 patients. Both occurred late after operation and were associated with prolapse of a leaflet of the autograft and significant regurgitation. Both were repaired with no immediate complications. There was no evidence of infection at time of operation. The probable mechanisms underlying this complication and the possibilities of avoiding it are discussed.
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Introduction
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Aortic valve replacement with autologous pulmonary valve (Ross procedure) is an attractive option for isolated aortic valve replacement. We adopted the Ross procedure as the procedure of choice in our young patients with aortic valve disease, which is almost 80% rheumatic in origin. We now have more than 200 patients who underwent the procedure during the past 8 years. We present 2 patients with aneurysm formation related to the pulmonary autograft in aortic position that may have contributed to autograft failure.
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Case reports
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Patient 1
A 22-year-old man with rheumatic aortic regurgitation underwent the Ross procedure. The autograft was implanted as a free-standing root using a running 4.0 Prolene suture that is interrupted at the commissures with reimplantation of the right coronary artery as a free button. The left coronary artery was kept attached to the aorta as a tongued pedicle. A postoperative transesophageal echocardiogram showed trivial autograft regurgitation. Two years later he presented with increasing dyspnea. Clinically and by a transthoracic echocardiogram, he was shown to have significant autograft regurgitation. A pulsating cavity posterior to the aorta was seen (Fig 1A). Transesophageal echocardiogram demonstrated this cavity to be communicating with the left ventricular outflow tract just distal to the suture line with the original aortic annulus (Fig 1B). At time of redo operation, all three autograft leaflets had an unusually large surface area, with prolapse of the right coronary leaflet. The cavity was found to be a false aneurysm originating in a gap below the left coronary leaflet. There was no evidence of infection. The false aneurysm was excised and the gap in the wall closed with direct suturing. The autograft was repaired by resuspension of the prolapsing leaflet. A year later the patient underwent successful aortic valve replacement with a homograft because of increasing aortic regurgitation of the repaired autograft.
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Fig 1. (A) Transthoracic echocardiogram in the parasternal long axis view in systole, of first patient, showing the cavity posterior to the aorta. (B) Transesophageal echocardiographic transverse plane in systole of same patient demonstrating the communication (arrowhead) between the left ventricular outflow tract and the cavity outlined by long arrows. (C) Transesophageal echocardiographic oblique plane (multiplanar at 135°) in systole of second patient showing the cavity posterior to the aorta, outlined by long arrows. (Ao = aorta; AV = aortic valve; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; MV = mitral valve.)
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Patient 2
A 28-year-old woman with rheumatic aortic and mitral regurgitation underwent the Ross procedure and mitral valve repair. The same surgical technique as described with patient 1 was used. A postoperative transesophageal echocardiogram showed no regurgitation. Three years later she presented with increasing exertional dyspnea. Clinically and by transesophageal echocardiogram, she was demonstrated to have moderately severe autograft regurgitation and moderately severe mitral regurgitation. A large, pulsating cavity was seen posterior to the aorta, and communicating with the left ventricular outflow tract (Fig 1C). At time of redo operation, both left and noncoronary leaflets were found to be stretched and redundant, with prolapse of the left coronary leaflet. There was no break in the left ventricular outflow tract and the cavity was a true aneurysm, resulting from thinning and outpouching of the remnant right ventricular muscular tissue in that area. There was no evidence of infection. Both the autograft and the mitral valve were replaced with mechanical prostheses. The mouth of the aneurysm was closed with pledgetted sutures. She remains asymptomatic 2 years after operation.
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Comment
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As of late, the Ross procedure has achieved renewal of interest and broader indications, especially in young patients [1–3]. This is due to safety of the procedure, improved implantation techniques, good long-term results, and potential for growth of the autograft. Autograft failure and need for reoperation has been attributed to technical errors, annular dilatation, cusp prolapse, infective endocarditis, rheumatic activity, and connective tissue disease [4,5]. A false aneurysm arising at the proximal suture line of a pulmonary autograft in the aortic position has been reported only once before [6]. Three other reports referred to single patients with false aneurysms with no details or explanation of the underlying cause.
In comparison to the aortic valve, the pulmonary valve lacks a discrete annulus. The pulmonary root is not supported by muscle of any consequence. When translocated, this unsupported area becomes exposed to systemic arterial pressure, with the potential for dilatation. Therefore, it is pertinent that the lower suture line of the autograft root must be onto the annulus of the removed aortic valve to give it support and hopefully, prevent progressive future dilatation. It is also important not to leave much right ventricular muscle, which is a potentially weak tissue at the proximal end of the autograft. Early in our experience, we used to leave more right ventricular muscle attached to the autograft to compensate for the size difference between a smaller pulmonary autograft and a dilated aortic root. It is very possible that the retained right ventricular muscle progressively weakened under the effect of the high systemic pressure leading to localized rupture and hence the false aneurysm in 1 patient, and to dilatation and a true aneurysm in the other. Probably the aneurysm formation has contributed to the autograft failure. Since then, our technique of autograft implantation has been modified. We now do a full root replacement with coronary transfer. The proximal suture line on the autograft is carefully placed to the rim of the leaflets, leaving no right ventricular muscle behind. Dilated roots are reinforced with autologous pericardium or Teflon felt. There has been no aneurysm formation in almost 100 patients who subsequently underwent the Ross procedure.
Aneurysm formation is a potential complication of both homograft and autograft replacement of the aortic root, possibly leading to valve regurgitation and need for reoperation. Careful attention in harvesting and preparing the autograft in addition to proper suture technique will definitely reduce the potential for such a problem.
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References
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Ross D.N. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet 1967;2:956-958.[Medline]
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Joyce F., Tingleff J., Pettersson G. Expanding indications for the Ross operation. J Heart Valve Dis 1995;4:352-363.[Medline]
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Kumar N., Gallo R., Gometza B., Al-Halees Z., Duran C.M.G. Pulmonary autograft for aortic valve replacement in rheumatic disease—an ideal solution?. J Heart Valve Dis 1994;3:384-387.[Medline]
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Chambers J.C., Somerville J., Stone S., Ross D.N. Pulmonary autograft procedure for aortic valve disease. Long-term results of the pioneer series. Circulation 1997;96:2206-2214.[Abstract/Free Full Text]
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Pieters F.A.A., Al-Halees Z., Zwaan F.E., Hatle L. Autograft failure after the Ross operation in a rheumatic population. J Heart Valve Dis 1996;5:404-409.[Medline]
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Metras D., Kreitmann B., Habib G., Riberi A., Yao J.G., Ross D.N. False aneurysm. J Heart Valve Dis 1996;5:414-417.[Medline]
Accepted for publication April 13, 1999.
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