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Ann Thorac Surg 1996;61:1145
© 1996 The Society of Thoracic Surgeons
DR CLINTON E. BAISDEN (Temple, TX):
In June of this year I did a Ross procedure on a 31-year-old man, who did fine after his operation until 6 weeks later when severe aortic insufficiency suddenly developed. Transesophageal echocardiography at the completion of his operation showed only trace aortic insufficiency, but now the echocardiogram suggested dilatation of his annulus.
After talking with Dr Elkins and some others, I proceeded to operate on the patient and, to my surprise, did not find annular dilatation, but a hole in the leaflet of his left coronary cusp about 4 by 5 mm in diameter. I was able to take a piece of his own pericardium to patch this and he has done well.
The point I want to make is that even though severe insufficiency may develop after the Ross procedure, it may be possible to correct it without too much difficulty.
Also, the pulmonary valve leaflets looked so delicate originally one wondered how they would ever hold up to systemic pressure. At reoperation, the valve looked almost like a normal aortic valve; the leaflets had enlarged, and they were better defined. It was quite reassuring.
DR ELKINS:
I think this really points out one of the facts that Mr Ross has identified for us, which is that the viable pulmonary autograft valve can be repaired; it can be treated as a normal aortic valve, for instance, that has a lesion-related endocarditis. I think the results really demonstrate one of the primary reasons for the enthusiasm for the pulmonary autograft.
MR DONALD ROSS (London, England):
I just want to stand up and congratulate Dr Elkins on another of his thoughtful and excellent presentations, and I would like to agree with what he said. I think it is important to have a restraining ring around the base of the valve replacement. Since we have moved to root replacement in autografts and homografts, we have put a ring around, not in selective cases but invariably. Whether that is right or wrong, I think it has paid off in the long run.
The only other point I would make is that we used to use a Teflon ring, and having had a severe infection in it, we now use only fresh pericardium. Doctor Elkins, what do you think about the use of autologous pericardium?
The report about the change of the thin pulmonary valve to a normal-looking aortic valve is very true. There was a case in the north of England in a patient who died of a heart attack about 10 years after I had put in an autograft: I received a letter suing me for not having done an operation because they did not recognize that the valve in the aortic position was not a true aortic valve.
DR ELKINS:
I am not about to try to top that. I think that there are situations where pericardium is an acceptable solution to this. My concern is that pericardium will dilate, and I have concern about what is going to happen to it long term. We have elected to use Teflon and Dacron primarily in those settings with marked dilatation.
Most of my patient population is in the younger age group-120 of the 199 patients are children-and we are very interested in growth in those. In those patients in whom we are concerned about growth, we have not done anything that would restrict growth and have not used an external cuff. The only time we have used it was in the 1 young child who was presented here who had marked discrepancy; we tried to size that child's annulus to a size that would allow some growth but would not cause failure of her autograft. Only time will tell us if that succeeded. I think the Dacron forms a very dense scar; that is what I want to happen and that is my reason for choice of it.
DR JOHN H. CALHOON (San Antonio, TX):
Doctor Elkins, that was a beautiful presentation. I would like one point of clarification. Is your preference at this point using the polypropylene sutures over a Dacron felt pledget and tying it down or using the Dacron felt externally?
DR ELKINS:
Actually, the Dacron cuff is external to the autograft attachment to the annulus and the sutures are tied over it. The only time we use pledget-to-suture material in this operation, for instance, is when we put in the annular suture that I described in the last technique.
DR CALHOON:
That is my question: do you use an annular suture preferentially or do you use the Dacron felt?
DR ELKINS:
We are using both. We actually use the annular suture and the felt. I think if I were operating tomorrow on a patient who had a 33-mm annulus, I would identify that patient's size, I would bring the annulus down to the appropriate size, fix it at that point, and put in an external ring, and I would know when I left the operating room that this patient had a 24-mm aortic annulus.
Related Article
Ann. Thorac. Surg. 1996 61: 1141-1145.
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