Ann Thorac Surg 2003;75:1518-1522
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure
Toru Ishizaka, MDa,
Eric J. Devaney, MDa,
Stephen R. Ramsburgh, MDb,
Takaaki Suzuki, MDa,
Richard G. Ohye, MDa,
Edward L. Bove, MDa*
a Division of Pediatric Cardiovascular Surgery, Section of Cardiac Surgery, Department of Surgery, Ann Arbor, Michigan, USA
b Department of Pathology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
Accepted for publication November 25, 2002.
* Address reprint requests to Dr Bove, Section of Cardiac Surgery, F7830 Mott Hospital, 1500 East Medical Center Dr, Ann Arbor, MI48109, USA.
e-mail: elbove{at}med.umich.edu
 |
Abstract
|
|---|
BACKGROUND: Aortic insufficiency secondary to progressive dilatation of the pulmonary autograft is being recognized with increasing frequency after the Ross procedure. We reviewed our experience with valve-sparing aortic root replacement concomitant with aortic annuloplasty to assess the effectiveness of this approach.
METHODS: Four patients, aged 8 to 27 years, presented with moderate to severe aortic insufficiency associated with progressive root dilatation from 1 to 8 years after a Ross procedure. All patients had 0 to 1+ aortic insufficiency early after the Ross procedure, with a mean maximal sinus diameter of 37 mm (range 30 to 45 mm). At reoperation the maximum diameter of the root ranged from 45 to 55 mm (mean 50 ± 4 mm). A valve-sparing aortic root replacement with annular reduction was performed. The annulus was decreased from a mean of 27 mm to 23 mm. For the root replacement, 1 patient underwent a standard root remodeling procedure; in the others, a separate piece of scalloped Dacron (C.R. Bard, Haverhill, PA) graft material was used for each sinus to facilitate optimal exposure.
RESULTS: All 4 patients are in New York Heart Association functional class I at a mean follow-up of 6 months. The most recent echocardiography demonstrated 0 to 1+ aortic insufficiency with good left ventricular function. Histology of the excised pulmonary autograft walls demonstrated severe elastin fragmentation.
CONCLUSIONS: Aortic root remodeling with annular reduction is an effective treatment for aortic root dilatation and aortic insufficiency after the Ross operation. This procedure allows correction of aortic insufficiency and avoids the need for a prosthetic valve and anticoagulation.
|
Introduction
|
|---|
Over the past decade, the use of the Ross procedure has increased dramatically. This can be attributed to its growth potential among infants and children, avoidance of anticoagulation and freedom from the risks of thromboembolism, valve-related morbidity, and structural valve deterioration. Although its use is justified by the reports of satisfactory long-term results [1–3], it has been increasingly recognized that in some patients progressive dilatation of the pulmonary autograft involving dilation of the sinotubular junction, sinuses of Valsalva, and autograft valve annulus may result in significant autograft regurgitation [4–6]. When the autograft valve leaflets remain normal, these patients may benefit from a valve-sparing root replacement operation. In this report, we describe our experience with reoperation for progressive autograft dilatation accompanied by aortic insufficiency after the Ross procedure.
|
Material and methods
|
|---|
Between October 2001 and May 2002, 4 male patients between the ages of 8 and 27 years were referred to our institution with aortic insufficiency and significant aortic root dilatation from 1 to 8 years after a Ross procedure. All patients originally underwent a complete root replacement technique. Demographic and diagnostic features are summarized in Table 1.
Patient 1 had previously undergone closure of a ventricular septal defect and resection of a subaortic membrane at 2 years of age. He underwent a Ross/Konno operation for aortic and subaortic stenosis with bicuspid aortic valve at the age of 5 years. The aortic annulus was enlarged from 11 to 17 mm by a partial thickness septal incision [7], and a pulmonary autograft with a diameter of 18 mm was implanted using a continuous polypropylene suture. A noncircumferential pericardial strip was used posteriorly and in the region of the right ventricular endocardium. Patient 2 had previously undergone open valvotomy for aortic stenosis due to a bicuspid aortic valve at 7 months of age. He underwent a Ross procedure for aortic regurgitation at the age of 14 years. At the time of the Ross operation, the diameter of the aortic annulus and the pulmonary autograft as measured with calibrated dilators were 24 and 26 mm, respectively. The autograft was implanted with a continuous polypropylene suture with a circumferential felt strip incorporated into the suture line. Patient 3 underwent Ross operation for a tricuspid aortic valve with aortic stenosis and insufficiency at the age of 21 years. A 29-mm pulmonary autograft was implanted without use of reinforcement of the aortic annulus, which was also measured at 29 mm in diameter. Patient 4 underwent Ross operation for a bicuspid aortic valve associated with aortic stenosis and insufficiency at the age of 12 years. At the time of the Ross operation, the aortic annulus was plicated from 28 to 24 mm, and a 25-mm pulmonary autograft was implanted with a circumferential strip of autologous glutaraldehyde-treated pericardium [8]. The degree of neoaortic insufficiency at early postoperative echocardiography after the Ross operation was 1+ in patients 1 and 4, trace in patient 2, and 0 in patient 3. Serial Doppler echocardiography demonstrated increasing aortic root dimensions with progression of central aortic insufficiency to 3+ or more in all 4 patients. In patient 4, in addition to the central insufficiency, there was a jet from a small defect at the base of the left coronary leaflet near the commissure of the left and the right coronary cusps. This jet had not been detected in the early postoperative studies. The function of the cryopreserved pulmonary allograft in the pulmonic position was normal in each patient and none were replaced.
Surgical technique
Reoperation was performed at an interval of 1 to 8 years after the Ross procedure (mean 4 ± 3 years). A valve-sparing aortic root replacement concomitant with an aortic annulus reduction procedure was performed. Data at reoperation are summarized in Table 2.
At reoperation, the valve leaflets appeared to be normal except in patient 4. In this patient, a 6-mm hole in the base of the left coronary leaflet was found, which was primarily closed with interrupted 6-0 Prolene (Ethicon, Somerville, NJ) sutures. There was no evidence of endocarditis and the remainder of the leaflets appeared to be normal. In each patient, annular reduction was performed with a circumferential continuous horizontal mattress suture of 2-0 Prolene. This was placed on the autograft wall just beneath the hinge point of the valve leaflets and passed outside of the wall at the noncoronary cusp, where it was tied down over a calibrated dilator (Fig 1A, 1B)
[9]. The size of the dilator was determined by comparison with the normal expected aortic annulus size based on the patient’s body surface area [10]. The sinuses of Valsalva were excised, sparing the coronary buttons and the commissural attachments of the valve leaflets. In patient 1, the root was reconstructed with a Hemashield graft fashioned with scallops (Meadox Medicals Inc, Oakland, NJ) to resuspend the autograft valve leaflets. In the remaining 3 patients, each sinus was reconstructed individually with a separate piece of scalloped graft, thereby facilitating exposure for the anastomosis of each sinus and the coronary buttons. The size of each scalloped graft was determined by first selecting a Dacron (C.R. Bard, Haverhill, PA) tube graft that was 2 mm smaller than the final aortic annular diameter. One end of the tube graft was then cut into three equal "sinuses," which were then used to replace the excised native sinus of Valsalva. The highest point of the valve commissure determined the height of each new sinus. After completing the root reconstruction, a Hemashield tube graft (Boston Scientific/Meadox, Oakland, NJ) was interposed between the newly reconstructed aortic root and the native aorta (Fig 2A, 2B).
The size of this graft was the same as that used to construct the separate sinuses except in patient 1, for whom a 20-mm (instead of 18-mm) graft was chosen because of likely continued growth. Each suture line except for the coronary buttons was buttressed by a Teflon (Impra Inc, subsidiary of L.R. Bard, Tempe, AZ) felt strip 3 mm in width.
View larger version (31K):
[in this window]
[in a new window]
|
Fig 1. (A) Placement of the annular reduction suture using continuous horizontal mattress stitch of 2-0 Prolene (Ethicon, Somerville, NJ) suture. (B) The suture is tied over the calibrated dilator to fix the size of the annulus.
|
|
View larger version (31K):
[in this window]
[in a new window]
|
Fig 2. (A) A separate piece of a scalloped graft was used for the reconstruction of each sinus to optimize exposure. (B) The coronary arteries are reimplanted and the same graft is interposed between the root and the ascending aorta.
|
|
|
Results
|
|---|
Postoperative data are listed in Table 3.
The degree of aortic insufficiency, as assessed by intraoperative transesophageal echocardiography, after repair was 0 in patient 1, trace in patients 2 and 3, and 1+ in patient 4. No blood transfusions were required in any case. All of the patients are doing well from 3 to 9 months after the operation, and the most recent Doppler echocardiographic assessments revealed no interval changes compared with the initial intraoperative results (0 to 1+ regurgitation).
Both the pulmonary autograft wall and the native ascending aorta were sent for histologic examination. In each case, the autograft wall demonstrated diffuse fragmentation and loss of elastic lamina with varying degrees of mucopolysaccharide deposition (Movat stain; Fig 3).
There was no discernible histologic change in the native ascending aortic wall.
View larger version (151K):
[in this window]
[in a new window]
|
Fig 3. A full-thickness section of resected pulmonary autograft in patient 2, showing diffuse fragmentation of elastic lamina and deposition of mucopolysaccharide (Movat stain, original magnification x200).
|
|
|
Comment
|
|---|
The valve annulus, sinuses of Valsalva, and sinotubular junction of the pulmonary autograft are known to show an increase in size after the Ross operation [4–6]. This increase may be secondary to passive dilatation due to exposure to higher blood pressure [11], mismatch of the pulmonary autograft and the aortic annulus or ascending aorta [8, 12], an intrinsic abnormality of the pulmonary root possibly associated with congenital aortic valve disease [5], or normal somatic growth in the pediatric population [13]. In the majority of cases the function of the autograft valve is preserved despite dilation of the aortic root [4, 6, 14]. However when the root dilatation leads to significant autograft valve insufficiency, or when the dilatation rapidly progresses into an aneurysm, reoperation is indicated. The treatment options are a Bentall procedure [15], rereplacement of the aortic root with a homograft [5, 16], replacement of the aortic valve with supported or unsupported aortoplasty [17], separate replacement of the aortic valve and the ascending aorta [18], or valve-sparing root replacement [19, 20]. In our own experience, in addition to the 4 patients in this report, 2 additional patients have required reoperation for autograft insufficiency (aortic valve replacement and Bentall operation in 1 patient each) among the initial 154 Ross operations performed in children and adolescents. We now prefer valve-sparing root replacement as a first option, as it obviates the need for anticoagulation and preserves the physiologic hemodynamics of the ventricular outflow, especially when the valve leaflets remain normal. Although the procedure described by David and colleagues is also an attractive option [20], it has been our preference to use the technique described here for its technical simplicity, particularly in younger children.
The appropriate timing of reoperation in this clinical setting has yet to be determined, especially in the pediatric population. David and colleagues [5] reported that reoperation is indicated when the aortic root dimension exceeds 55 mm in diameter. Although the sizes in our cases did not exceed this criterion, earlier intervention for these patients is likely to increase the chances of preserving the autograft valve.
Recently, Sundt and colleagues [21] reported a case of valve-sparing root replacement for root dilatation without autograft valve regurgitation after a Ross procedure. Our 4 cases were complicated by significant aortic insufficiency due to dilatation of the sinotubular junction as well as dilatation of the autograft annulus and sinuses of Valsalva. Therefore, a reduction annuloplasty with a circumferential pursestring suture was placed below the annulus in addition to the aortic root remodeling, as described by Elkins and associates [9, 22]. They described the use of the reduction annuloplasty at reoperation after the Ross operation in patients with central insufficiency and aortic annular dilatation. They also reported the use of that technique at the time of the Ross operation in patients with a dilated annulus, demonstrating satisfactory late results with no increase in size of the annulus or in valve insufficiency.
Morishita and coworkers [23] have supported the use of tripartite scalloped grafts for the reconstruction of the sinuses of Valsalva, based on the observation that each aortic sinus is not equal in size in human cadavers. Although the use of this technique requires an additional graft-to-graft anastomosis, it provides improved exposure of the suture line for each scallop and the coronary buttons. Moreover, tailoring the graft to the exact size of each sinus is facilitated, making mathematical formulas unnecessary.
Histologic abnormalities of pulmonary arterial wall media, including elastin fragmentation (as observed in our patients), changes in smooth muscle cell orientation, and cystic medial necrosis have been reported by several authors [16, 21, 24]. Although we cannot determine whether the striking histologic features of the autograft media in our cases represent a preexisting abnormality, the findings support the concept that technical considerations to prevent root dilatation at the Ross operation are warranted, as well as careful annual echocardiographic monitoring after the Ross operation. We currently prefer a circumferential Dacron strip around the aortic annulus and the sinotubular junction as reinforcement during the Ross operation in adolescents and older patients, although its efficacy for preventing dilatation is yet to be determined. Furthermore, this would not be expected to prevent dilatation at the sinus level.
In conclusion, an aortic root remodeling operation and autograft valve repair with an annular reduction suture is an effective alternative for the treatment of aortic root dilatation and autograft valve insufficiency after the Ross operation. This procedure allows correction of valve insufficiency and avoids the need for a prosthetic valve and anticoagulation. Although this is a small series with a short follow-up period, the preliminary results are encouraging.
|
References
|
|---|
- Ross D., Jackson M., Davies J. Pulmonary autograft aortic valve replacement: long-term results. J Card Surg 1991;6:529-533.[Medline]
- Oury J.H., Mackey S.K., Duran C.M.G. Critical Analysis of the Ross procedure: do its problems justify wider application?. Semin Thorac Cardiovasc Surg 1999;11(Suppl 1):55-61.[Medline]
- Kouchoukos N.T., Davila-Roman V.G., Spray T.L., Murphy S.F., Perrillo J.B. Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic valve disease. N Engl J Med 1994;57:1387-1394.
- Hokken R.B., Bogers A.J.J.C., Taams M.A., et al. Does the pulmonary autograft in the aortic position in adults increase in diameter? An echocardiographic study. J Thorac Cardiovasc Surg 1997;113:667-674.[Abstract/Free Full Text]
- David T.E., Omran A., Ivanov J., et al. Dilation of the pulmonary autograft after the Ross procedure. J Thorac Cardiovasc Surg 2000;119:210-220.[Abstract/Free Full Text]
- Solymar L., Sudow G., Holmgren D. Increase in size of the pulmonary autograft after the Ross operation in children: growth or dilatation?. J Thorac Cardiovasc Surg 2000;119:4-9.[Abstract/Free Full Text]
- Ohye R.G., Gomez C.A., Ohye B.J., Goldberg C.S., Bove E.L. The Ross/Konno Procedure in neonate and infants: intermediate-term survival and autograft function. Ann Thorac Surg 2001;72:823-830.[Abstract/Free Full Text]
- Durham L.A., desJardins S.E., Mosca R.S., Bove E.L. Ross procedure with aortic root tailoring for aortic valve replacement in the pediatric population. Ann Thorac Surg 1997;64:482-486.[Abstract/Free Full Text]
- Elkins R.C., Knott-Craig C.J., Howell C.E. Pulmonary autografts in patients with aortic annulus dysplasia. Ann Thorac Surg 1996;61:1141-1145.[Abstract/Free Full Text]
- Daubeney P., Blackstone E., Weintraub R., Slavik Z., Scanlon J., Webber S. Relation of the dimensions of cardiac structures to body size. An echocardiographic study in normal infants and children. Cardiol Young 1999;9:402-410.[Medline]
- Puntel R.A., Webber S.A., Ettedgui J.A., Tacy T.A. Rapid enlargement of neoaortic root after the Ross procedure in children. Am J Cardiol 1999;84:747-749.[Medline]
- Laudito A., Brook M.M., Suleman S., et al. The Ross procedure in children and young adults: a word of caution. J Thorac Cardiovasc Surg 2001;122:147-153.[Abstract/Free Full Text]
- Elkins R.C., Knott-Craig C.J., Ward K.E., McCue C., Lane M.M. Pulmonary autograft in children: realized growth potential. Ann Thorac Surg 1994;57:1387-1394.[Abstract]
- Tantengco M.V.T., Humes R.A., Clapp S.K., et al. Aortic root dilatation after the Ross procedure. Am J Cardiol 1999;83:915-920.[Medline]
- Bentall H., DeBono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
- Takkenberg J.J.M., Zondervan P.E., Herwerden L.A. Progressive pulmonary autograft root dilatation and failure after Ross procedure. Ann Thorac Surg 1999;67:551-554.[Abstract/Free Full Text]
- Bauer M., Pasic M., Schaffarzyk R., et al. Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve. Ann Thorac Surg 2002;73:720-724.[Abstract/Free Full Text]
- Yun K.L., Miller D.C., Fann J.I. Composite valve graft versus separate aortic valve and ascending aortic replacement: is there still a role for the separate procedure. Circulation 1997;96(Suppl 1):368-375.
- Sarsam M.A., Yacoub M. Remodeling of the aortic valve annulus. J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
- David T.E., Feindel C.M., Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345-352.[Abstract/Free Full Text]
- Sundt T.M., Moon M.R., Xu H. Reoperation for dilatation of the pulmonary autograft after the Ross procedure. J Thorac Cardiovasc Surg 2001;122:1249-1252.[Free Full Text]
- Elkins R.C., Lane M.M., McCue C. Pulmonary autograft reoperation: incidence and management. Ann Thorac Surg 1996;62:450-455.[Abstract/Free Full Text]
- Morishita K., Murakami G., Koshino T., et al. Aortic root remodeling operation: how do we tailor a tube graft?. Ann Thorac Surg 2002;73:1117-1121.[Abstract/Free Full Text]
- de Sa M., Moshkovitz Y., Butany J., David T.E. Histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid aortic valve disease: clinical relevance to the Ross procedure. J Thorac Cardiovasc Surg 1999;118:588-596.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
M. Ono, H. Goerler, D. Boethig, M. Westhoff-Bleck, and T. Breymann
Current surgical management of ascending aortic aneurysm in children and young adults.
Ann. Thorac. Surg.,
November 1, 2009;
88(5):
1527 - 1533.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. Alsoufi, Z. Al-Halees, C. Manlhiot, B. W. McCrindle, M. Al-Ahmadi, A. Sallehuddin, C. C. Canver, Z. Bulbul, M. Joufan, and B. Fadel
Mechanical valves versus the Ross procedure for aortic valve replacement in children: Propensity-adjusted comparison of long-term outcomes.
J. Thorac. Cardiovasc. Surg.,
February 1, 2009;
137(2):
362 - 370.e9.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Ono, H. Goerler, D. Boethig, M. Westhoff-Bleck, D. Hartung, and T. Breymann
Valve-Sparing Operation for Aortic Root Aneurysm Late After Mustard Procedure
Ann. Thorac. Surg.,
June 1, 2007;
83(6):
2224 - 2226.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. W. Brown, M. Ruzmetov, M. D. Rodefeld, Y. Mahomed, and M. W. Turrentine
Incidence of and Risk Factors for Pulmonary Autograft Dilation After Ross Aortic Valve Replacement
Ann. Thorac. Surg.,
May 1, 2007;
83(5):
1781 - 1789.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. K. Pasquali, M. S. Cohen, D. Shera, G. Wernovsky, T. L. Spray, and B. S. Marino
The Relationship Between Neo-Aortic Root Dilation, Insufficiency, and Reintervention Following the Ross Procedure in Infants, Children, and Young Adults
J. Am. Coll. Cardiol.,
May 1, 2007;
49(17):
1806 - 1812.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Ono, H. Goerler, K. Kallenbach, D. Boethig, M. Westhoff-Bleck, and T. Breymann
Aortic valve-sparing reimplantation for dilatation of the ascending aorta and aortic regurgitation late after repair of congenital heart disease
J. Thorac. Cardiovasc. Surg.,
April 1, 2007;
133(4):
876 - 879.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. W. Brown, M. Ruzmetov, P. Vijay, M. D. Rodefeld, and M. W. Turrentine
The ross-konno procedure in children: outcomes, autograft and allograft function, and reoperations.
Ann. Thorac. Surg.,
October 1, 2006;
82(4):
1301 - 1306.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. G. Pennington
The Impact of New Technology on Cardiothoracic Surgical Practice
Ann. Thorac. Surg.,
January 1, 2006;
81(1):
10 - 18.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. El-Essawi, J. Sanger, S. Ulrich, I. Kutschka, and W. Harringer
Aortic valve-sparing operation for autograft failure after the Ross procedure
J. Thorac. Cardiovasc. Surg.,
October 1, 2005;
130(4):
1215 - 1216.
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. L. Vida, T. Bottio, O. Milanesi, E. Reffo, R. Biffanti, R. Bonato, and G. Stellin
Critical Aortic Stenosis in Early Infancy: Surgical Treatment for Residual Lesions After Balloon Dilation
Ann. Thorac. Surg.,
January 1, 2005;
79(1):
47 - 51.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Hraska, M. Krajci, Ch. Haun, K. Ntalakoura, V. Razek, F. Lacour-Gayet, J. Weil, and H. Reichenspurner
Ross and Ross-Konno procedure in children and adolescents: mid-term results
Eur. J. Cardiothorac. Surg.,
May 1, 2004;
25(5):
742 - 747.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
