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Ann Thorac Surg 2001;72:1610-1614
© 2001 The Society of Thoracic Surgeons
a Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
b Penn State Children’s Hospital, Hershey, Pennsylvania, USA
* Address reprint requests to Dr Pigula, Pediatric Cardiothoracic Surgery, Room 2820, 2 Main, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15213, USA
e-mail: pigulaf{at}heart.chp.edu
Presented at the Thirty-seventh annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.
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Abstract |
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Methods. Retrospective review of 15 patients undergoing Ross operation without aortic annular modification (group 1), 11 patients requiring annular reduction (group 2, n = 11), and 8 patients requiring annular enlargement (group 3, n = 8). Autograft function and dimensions were evaluated by echocardiography.
Results. Autograft insufficiency was less than or equal to mild in 33 patients and moderate in 1 patient. The annulus body surface area ratio increased in group 1 from 19.7 ± 5 to 20.3 ± 5 mm/m2 (p = 0.8). The average annular reduction in group 2 was 5 ± 1.5 mm, and 10 of 11 patients required reduction of the ascending aorta (mean 11 ± 5 mm). The annulus body surface area ratio increased from 18.6 ± 7 to 20.5 ± 9 mm/m2 (p = 0.2). The mean augmentation in annulus diameter in group 3 was 6 ± 4 mm; the annulus body surface area ratio decreased from 23.7 ± 14 to 20.3 ± 8 mm/m2 (p = 0.5).
Conclusions. We continue to offer the Ross operation to pediatric patients even when aortic annular or ascending aortic size discrepancies mandate surgical modifications.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentDiscussionReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentDiscussionReferences |
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18 years) undergoing the Ross operation between 1995 and 2000. Data were obtained from review of patient charts, operative notes, and review of echocardiographic data. Echocardiographic measurements, obtained from the parasternal long axis, were routinely performed for evaluation of autograft annular dimensions and function. For the purposes of comparison, autograft annular dimensions were standardized to body surface area (BSA) [1]. The annulus BSA ratio was calculated at the time of operation and again at most recent follow-up. Data are presented as mean ± the standard deviation, and statistical comparisons were made by analysis of variance.
Patients
Thirty-seven pediatric patients ( 18 years) undergoing the Ross operation between 1995 and 2000 were reviewed. Thirty-four patients receiving a root replacement were reviewed; 3 patients receiving subcoronary implantation were excluded. The average age was 10 ± 6 years (4 months to 18 years), with a mean follow-up of 17 ± 16 months. Seventeen patients had aortic stenosis, 3 patients had insufficiency, and 14 patients had both.
Technique
Intraoperative transesophageal echocardiography was performed on all patients. After excision of the diseased aortic valve, the annulus was sized with a calibrated dilator. Likewise, the pulmonary artery was incised at the bifurcation, and the pulmonary valve was inspected and sized. The pulmonary valve was sized to gentle expansion and no more with the dilator. From these measurements, the aortopulmonary size discrepancies were calculated. Echocardiographic evaluation of the autograft was performed at the time of insertion and again at follow-up. Measurements of the autograft annulus were obtained in the parasternal long axis view with measurements obtained at the hinge points of the valve leaflets.
Fifteen patients required no surgical modification of the aortic annulus to accommodate the autograft (group 1). There were 11 patients (group 2) with aortic annular dimensions exceeding those of the autograft by greater than or equal to 3 mm that underwent annular reduction.
Annular reduction was accomplished by one of three techniques: (1) Annular plication (n = 8) using pledget 2-0 Ethibon sutures (Ethibon, Ethicon Inc, Somerville, NJ) at the level of the aortic annulus; this plication extends anteriorly from the right fibrous trigone of the mitral valve, depending upon the degree of reduction required. Care is taken to remain above the membranous septum and conduction axis. The plicated area is then included in the reinforced annular anastomosis (Fig 1). (2) Purse string reduction (n = 2) allows a well-defined reduction of the aortic annulus over a Hegar dilator to the measured autograft dimension. We have used this technique when the aortic annulus exceeds the autograft diameter by greater than or equal to 6 mm (Fig 2) [2]. (3) Annular reduction was achieved in 1 patient using the technique of posterior annular excision and reapproximation as described by Durham and colleagues [3] (Fig 3).
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Eight patients requiring augmentation of the left ventricular outflow tract (group 3) underwent the Ross-Konno operation [4, 5]. Root replacement was performed using a continuous suture technique, with support of the annular anastomosis in all patients. When autograft growth was believed to be important, the suture line was reinforced with fresh autologous pericardium. Children nearing completion of somatic growth and autografts greater than or equal to 20 mm were supported with a continuous strip of Teflon felt (Meadox Medical, Oakland, NJ).
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Results |
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Although no patient required reoperation for autograft dysfunction, there were two late reoperations; 1 patient with a well functioning autograft required heart transplantation secondary to progressive left ventricular fibroelastosis and pulmonary hypertension 3 years after Ross-Konno (group 3), and 1 patient required placement of a permanent pacemaker 2 years after a Ross operation for sick sinus syndrome (group 1).
Follow-up was similar between all groups (Table 1). The mean annulus BSA ratio increased only slightly in group 1 (19.7 ± 5 vs 20.3 ± 5 mm/m2, p = 0.8). The average reduction in aortic annulus diameter in group 2 was 5 ± 1.5 mm (range, 4 to 7 mm). Among the 10 patients in group 2 requiring surgical reduction of the ascending aorta, an average of 11 ± 5 mm (range, 5 to 20 mm) were resected from the circumference. Although the annulus BSA ratio did increase from 18.6 ± 7 mm/m2 to 20.5 ± 9 mm/m2 in these patients, this change did not achieve statistical significance (p = 0.2). No group 2 patient demonstrated more than mild autograft regurgitation. The average augmentation of the annulus diameter in group 3 was 7 ± 3 mm (range, 4 to 10 mm). Among these patients, the annulus BSA ratio actually decreased during follow-up, from 23.7 ± 14 to 20.3 ± 8 mm/m2 (p = 0.5).
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Using linear regression analysis of serial echocardiographic measurements, we examined the rate of change of the raw annular dimensions for each group (Fig 4). The average rate of change, reflected by the slope, was similar between all groups, and suggests that the rate of change of annular dimensions are similar. At most recent follow-up, 33 patients have trivial to mild autograft regurgitation, and 1 patient from group 3 had moderate autograft regurgitation.
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Comment |
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However, because of the anatomic and physiologic variants sometimes present in patients with congenital heart disease, important size discrepancies may develop between the diseased aorta and the pulmonary autograft. Once believed to be a contraindication to the Ross operation, a lack of alternatives has prompted attempts at surgical modification of the aortic annulus so that the autograft may be accommodated.
The fate of autografts inserted into the surgically modified aortic annulus remains uncertain, however. Durham and colleagues [3] reported their experience in 15 children and young adults that required annular reduction to accommodate the autograft. They reported excellent and stable autograft function over the short term (mean follow-up, 6 months). Elkins and colleagues [2] reported their experience in 20 patients (7 patients 18 years of age) with aortic annulus dysplasia requiring annular reduction at the time of the Ross operations. Although the follow-up was limited, they reported excellent autograft function without progressive autograft insufficiency.
Reddy and colleagues [8] reported 9 patients in which the aortic annulus was at least 3 mm larger than the autograft. They utilized the infundibular muscle with a running suture technique to accomplish size compatibility, without external fixation or support of the anastomosis. With a median follow-up of 31 months, they found no correlation between the aortopulmonary size mismatch and the subsequent development of autograft insufficiency. The authors concluded that aortopulmonary size mismatch is not a contraindication to the Ross operation in children.
Likewise, our data suggests that there are no significant differences in the behavior of the modified annulus as it relates to the development of autograft dilatation or insufficiency over the follow-up period. Although patients requiring annular reduction (group 2) demonstrated a small increase of the annulus BSA ratio, this increase did not reach statistical significance. More importantly however, none of these patients developed clinically significant autograft insufficiency. It is interesting to note that the annulus BSA ratio decreased in patients undergoing the Ross-Konno operation. This finding probably represents increased somatic growth in ill children after surgical relief of their left ventricular outflow tract obstruction.
From the three reduction techniques used, we favored annular plication when possible. If, because of the degree of aortic annular dilatation, plication would result in an inadequate reduction, we proceeded with purse string reduction, similar in concept to that reported by Elkins and colleagues [7]. Because these techniques maintain the integrity of the annulus and aortomitral continuity, they are probably superior to posterior annular resection and reapproximation [3, 9, 10].
Like others, we believe it is important to provide anastomotic support at the annular level to minimize the late development of autograft insufficiency [11]. We believe that any autograft greater than or equal to 20 mm should be fixed; we routinely use a continuous felt Teflon strip, but the material is probably of little consequence. If further annular growth is to be expected, we have used fresh autologous pericardium. We do not, however, have any data relating to appropriate autograft growth and the various treatments of the annular anastomosis.
Surgical treatment of the ascending aorta was also required in the majority of patients undergoing annular reduction. Although this most commonly took the form of a wedge-shaped excision of the ascending aorta, 1 patient required replacement of a dilated ascending aorta (Hemashield, Bard Meadox Medical, Oakland, NJ) that culminated in a stenosis at the base of the innominate artery (arterial cannulation site after neonatal open aortic valvotomy). Although we did not specifically address the impact of resection or replacement of a dilated ascending aorta on autograft function, our results are consistent with reports that suggested the durability of surgically treated aortic disease at the time of the Ross operations were excellent [11].
In summary, although the long-term consequences of annular modification in the Ross operation remain unknown, there are few alternatives for some children. Children requiring surgical modification of the aortic annulus to accommodate the autograft have demonstrated excellent autograft function with no increase in the rate of annular enlargement over the follow-up period. Therefore, we continue to recommend the Ross operation for pediatric patients with congenital heart disease, even when aortic annular or ascending aortic size discrepancies mandate surgical modifications to accommodate the autograft. However, continued follow-up with echocardiographic examination of the autograft and ascending aorta, as well as the aortic annulus, is necessary to understand the ultimate fate of these autografts.
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Discussion |
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I am concerned about the question of the Ross in children with autograft insuffiency (AI). Dr Hanley presented an article last year at The American Association of Thoracic Surgeons with the warning that children with AI should perhaps be looked at severely as far as proceeding with a Ross procedure.
Yesterday, Dr Bove’s group presented 10 patients with the Ross-Konno operation with 2 patients developing AI over a period of time. Your follow-up time is approximately 2 years, and you have 1 child out of 8 with AI after the Ross-Konno procedure.
Are you not concerned or could you express, perhaps, your opinion about doing the Ross in children with AI and also with the question of doing a Ross-Konno procedure with the possibility that AI might develop in the next 5 to 10 years?
DR PIGULA: Is the question whether they have preoperative AI in the indications for a Ross operation?
DR AMATO: That is correct. Dr Hanley’s article discussed patients with preoperative AI. Yesterday’s article discussed 10 patients with Ross-Konno, with 2 of the 10 developing 10 patients with Ross-Konno, with 2 of the 10 developing AI. Your article today presents a total of 8 patients with 1 patient developing AI postoperatively. These results caution us to be concerned over the long term of development of AI as patients grow with possible dilation of the annulus.
DR PIGULA: Thank you. That’s a good point.
Part of, I think, when we interpret the amount of aortic insufficiency is how it is judged. And we routinely will judge that with echocardiograms. I think we have sometimes seen discrepancies on what is termed mild or moderate aortic insufficiency as compared to the catheterization data. In short, sometimes the echocardiogram will overestimate the degree of aortic insufficiency.
That being said, there is clearly a subgroup of patients that will fail the Ross operation. They will demonstrate progressive AI either because of aorto-annular dilation or sinotubular dilation that will lead to failure of the Ross operation.
As with anything else, we have to take into account our options. In some of these children there really are no satisfactory or superior options to the Ross in that setting, and we take the best option we have available, and for many of the patients it is the Ross operation, understanding there are limitations, of course.
DR TOM R. KARL (Philadelphia, PA): May I ask about the limits of this strategy for patients with very specific pathology such as annuloectasia syndrome, Marfan syndrome, and so forth? Do you have a point at which you would say that the operation is likely to fail early because of an extreme degree of dilation and perhaps take a different approach?
DR PIGULA: In my opinion, clearly, any patient with an identifiable genetic disorder should not be a candidate for Ross.
As far as size discrepancies, is there an absolute size discrepancy in the absence of an identifiable genetic disorder? I have not encountered that sizable discrepancy yet. The greatest discrepancy in diameter we have encountered is about 7 mm. And it remains to be seen whether those are durable or not.
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This article has been cited by other articles:
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  F. A. Pigula, C. B. Mahnke, P. Agnastopolous, A. Casta, R. Munoz, and S. K. Gandhi Closed correction of systemic semilunar valve insufficiency in the neonate J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1650 - 1652. [Full Text] [PDF]
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6 mm diameter) were treated with purse string reduction of the aortic annulus, sized over a Heger dilator.
