Ann Thorac Surg 2002;73:1988-1989
© 2002 The Society of Thoracic Surgeons
How to do it
Double-switch Ross procedure
Jen-Ping Chang, MD*a,
Chiung-Lun Kao, MDa,
Ming-Jang Hsieh, MDa
a Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, Republic of China
Accepted for publication January 22, 2002.
* Address reprint requests to Dr Chang, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Kaohsiung, 123, Ta-Pei Rd, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan, Republic of China ROC
e-mail: c9112772{at}adm.cgmh.org.tw
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Abstract
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Aortic root replacement with pulmonary autograft (Ross procedure) is a valuable technique. However, the best material for right ventricular outflow tract reconstruction remains controversial. We report on the experience with use of an aortic autograft with reimplantation of the diseased aortic valve for right ventricular outflow tract reconstruction in 3 patients with satisfactory result.
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Introduction
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Currently, a pulmonary homograft is preferred worldwide as the right ventricular outflow tract (RVOT) substitute in the Ross procedure. Lack of a pulmonary homograft limits use of the Ross procedure in many parts of the world. To circumvent this problem, several alternatives have been reported. Most of these alternatives are composite grafts of autologous tissue and artificial materials (polytetrafluoroethylene) or a porcine bioprosthesis [1–6]. They have their own limitations regarding growth potential or valvular competency. We report on our experience with use of a stepladder-shaped aortic autograft with reimplantation of the diseased aortic valve for RVOT reconstruction, which we call a double-switch Ross procedure.
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Technique
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A median sternotomy is performed. The pericardium is incised along the right mediastinal margin to make a pedicled rectangular flap. The procedure is performed with moderate hypothermic cardiopulmonary bypass and antegrade cardioplegia. The pulmonary autograft is harvested in the classic fashion of the Ross procedure.
A transverse aortotomy is made just distal to the right coronary orifice, and a stepladder-shaped aortic autograft is harvested (Figs 1,2).
The diseased aortic valve is excised carefully and delivered to the cosurgeon with the harvested aortic autograft to reimplant the excised leaflets to the proximal end of the aortic autograft. A piece of bovine pericardium is sutured to the future posterior margin of the proximal end of the aortic autograft for reconstruction of the posterior RVOT defect (Fig 3). The pulmonary autograft is implanted in the aortic root, and a bilateral coronary button is anastomosed to the graft in the usual manner. A continuous suture with 5-0 polypropylene is used to anastomose the posterior wall of the pulmonary autograft and the residual distal aortic posterior stump. The anterior aortic wall defect is repaired with a piece of bovine pericardial patch. The proximal side of the stepladder-shaped aortic autograft and the RVOT are anastomosed directly. The posterior distal side of the graft is sutured to the posterior wall of the pulmonary arteriotomy. The distal anterior wall of the aortic autograft is reconstructed with a pedicled autologous pericardial flap with monofilament absorbable interrupted sutures (Fig 4).
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Fig 1. Stepladder-shaped aortectomy was made to harvest the aortic autograft; the pulmonary autograft was harvested as usual.
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Fig 3. A piece of bovine pericardium is sutured to the proximal end of the aortic autograft for reconstruction of the posterior right ventricular outflow tract defect; note the reimplanted valve.
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Results
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Three teenagers (mean age, 18 years; 2 girls, 1 boy) with severe rheumatic aortic stenosis regurgitation underwent this technique of double-switch Ross procedure.
There were no hospital and late deaths. In a mean follow-up of 52 months (range, 50 to 53 months), serial echocardiography in all patients revealed trivial aortic regurgitation without a pressure gradient across the neoaortic valve. The neopulmonic valve showed mild stenosis (instantaneous pressure gradient by continuous wave Doppler echocardiography, mean, 40 mm Hg; range, 38 to 42 mm Hg), and trivial pulmonary reguritation.
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Comment
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Currently, the indication for the Ross procedure is expanding. Autografts show excellent longevity, clear hemodynamic superiority, infection resistance, and freedom from anticoagulation. These characteristics are attractive even though the procedure is complex and time-consuming. A pulmonary homograft is accepted worldwide as a material useful for the RVOT reconstruction in Ross procedure. Although a pulmonary homograft is preferred and lasts longer in the pulmonary position, replacement nevertheless will be needed. Furthermore, developing countries in which homografts are not available do not have an acceptable alternative. Thus, numerous types of conduits have been developed, each with its own advantages and disadvantages, to connect the right ventricle to the pulmonary artery, hopefully to circumvent those problems.
Most of these alternatives are composite grafts of autologous tissue and artificial materials (polytetrafluoroethylene) or a porcine bioprosthesis [1–6]. They have their own limitations regarding growth potential or valvular competency. In contrast, the stepladder-shaped aortic autograft seems indeed to circumvent those problems in most cases.
Our technique has several issues. First of all, the use of autologous pedicled pericardial patch to repair the anterior defect of the neopulmonary artery is an important issue. It is reported that RVOT reconstruction with autologous pedicled pericardium is useful to prevent late stenosis because the pedicled pericardium was more pliable and less fibrotic [7]. Therefore, this neopulmonary artery is expected to have good longevity. Another issue is the role of the reimplanted aortic tricuspid valve. Usually, the tricuspid valve is considered more effective than the monocuspid valve in preventing pulmonary regurgitation even when the valve is diseased [2]. To avoid cusp adhesion to the conduit wall, we used no prosthetic material. Therefore, the reimplanted cusps should be as long as possible, and potential growth of the valve reimplanted aortic autograft may be expected.
In conclusion, we would like to emphasize that the aortic autograft with reimplanted aortic valve and pedicled autologous pericardial patch may be a good alternative for RVOT reconstruction in the Ross procedure with expectations of a functioning, reimplanted tricuspid aortic valve, of preventing late stenosis, and of potential conduit growth.
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References
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Urrea M.S., Herrena V., Rey A., Vargus J. Ross operation using a bovine bioprosthetic valve with autologous pericardial conduit in the pulmonary position. Tex Heart Inst J 1993;20:271-274.[Medline]
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DeLeon S.Y., Quinones J.A., Miles R.H., et al. Use of the native aortic valve as the pulmonary valve in the Ross procedure. Ann Thorac Surg 1995;59:1007-1010.[Abstract/Free Full Text]
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Morishita K., Abe T., Fukada J., Sato H., Shiiku C. Alternative to reconstruction of the pulmonary outflow tract in the Ross procedure. Ann Thorac Surg 1998;66:549-550.[Abstract/Free Full Text]
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Yamagishi M., Emmoto T., Wada Y., Oka T. Pulmonary reconstruction in the Ross procedure: combined autologous aortic and polytetrafluoroethylene valve. J Thorac Cardiovasc Surg 1998;116:1076-1077.[Free Full Text]
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Tabayashi K., Tanaka Y., Endo M., Sai S., Masuda S., Sadahiro M. Right ventricular outflow reconstruction with nonsutured pedicled autologous pericardium. J Thorac Cardiovasc Surg 2001;121:1203-1205.[Free Full Text]
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Marianeschi S.M., Iacona G.M., Seddio F., et al. Shelhigh no-react porcine pulmonic valve conduit. A new alternative to the homograft. Ann Thorac Surg 2001;71:619-623.[Abstract/Free Full Text]
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Sato K., Iguchi A., Tanaka Y., et al. Pedicled pericardial flap for pulmonary artery in adult dogs. Jpn J Thorac Cardiovasc Surg 2000;48:211-216.[Medline]
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Abstract
Introduction
