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Ann Thorac Surg 2001;72:1495-1496
© 2001 The Society of Thoracic Surgeons
a Division of Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth St, 14EN-222, Toronto, Ontario M5G 2C4, Canada
e-mail: chris.feindel{at}uhn.on.ca
Doctor Prat and his associates present a small series of 11 patients with complex aortic root endocarditis with paravalvular involvement who were successfully treated with a pulmonary autograft (Ross Procedure). All patients were very ill at the time of surgery, either due to sepsis or to hemodynamic compromise. In fact, one patient was in cardiogenic shock. There were no deaths and surprisingly little perioperative morbidity. Recurrent endocarditis had not occurred in any of these patients during the median follow up of 40 months.
This is clearly an outstanding series. The authors are to be congratulated for their ability to manage this challenging and complex group of patients with an equally challenging and complex operation with such excellent results. Notwithstanding my praise for these superb results I cannot support the authors conclusion that "The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis".
The Ross operation may be excellent for young individuals requiring aortic valve replacement surgery. A number of reports suggest superior long-term results of the Ross operation compared to any other aortic valve replacement procedure. Yet, even in the hands of highly skilled surgeons, the Ross operation is difficult and time consuming. It is also, according to the Ross Registry, associated with a higher perioperative mortality and morbidity compared to conventional isolated aortic valve replacement [1]. Only skilled surgeons who have performed a large number of these procedures are able to do so with acceptably low mortality and morbidity. Finally, and perhaps the greatest concern of the Ross Operation, is that a patient who comes to hospital with single valve disease leaves with the potential for double valve disease. Despite these drawbacks the advantages of the Ross operation may outweigh its disadvantages in highly selected patients.
Should a patient, even a young one, with complex aortic root endocarditis of the type described by Prat undergo a Ross procedure? I believe they should not and wonder why a surgeon would expose such a patient, who already faces substantial risks of radical aortic root surgery, to even further risk of a Ross procedure? Almost all cardiac surgeons from time to time will face patients with aortic root infection. In these cases I recommend that surgeons take out the infected valve and the surrounding tissue, do so completely, and carefully reconstruct the outflow tract with autologous or heterologous pericardium [2, 3]. As long as all infected material is removed it probably makes little difference what prosthetic device or conduit is used as far as recurrent infection is concerned. However, I would not recommend using the pulmonary autograft. With careful attention to detail and using good cardiac protection these patients will usually do well.
The key sentence in Dr Prat’s article is the statement that "surgery was done by one of us". Dr Prat is clearly one of a small group of highly skilled surgeons around the world who can do the Ross procedure very well. Dr Prat’s series should be viewed simply for what it is, that is it shows what a gifted surgeon is capable of doing. It should not be viewed as a recommendation to all to do Ross operations in patients with complex aortic root endocarditis.
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