Size and distensibility of the aortic root and aortic valve function after different techniques of the Ross procedure

Schmidtke, Claudia; Bechtel, Jfm; Hueppe, Michael; Noetzold, Axel; Sievers, Hans‐Hinrich

doi:10.1016/s0022-5223(00)70094-8

Cited by 42 publications

(25 citation statements)

References 18 publications

(23 reference statements)

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“…6,16 Although we could not detect a progressive dilatation of the aortic root up to 21 months after the operation in our first 10 patients with a freestanding aortic root, 8 2 of them developed sinus diameters Ͼ50 mm at Ն7 years postoperatively. 17 The duration of the high-pressure load on the autograft probably has a dilating effect on the pulmonary root, but this remains to be established in other studies with more patients and a longer follow-up period. Theoretically, this dilatation, especially at the sinotubular junction, may have some impact on the progression of aortic insufficiency, which was reported to occur occasionally after the Ross procedure especially if the freestanding root technique was used.…”

Section: Discussionmentioning

confidence: 95%

Time Course of Aortic Valve Function and Root Dimensions After Subcoronary Ross Procedure for Bicuspid Versus Tricuspid Aortic Valve Disease

Schmidtke

Bechtel²,

Hueppe³

et al. 2001

Circulation

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Background-The freestanding aortic root, which is the currently preferred operative technique for pulmonary autografts, is reported to dilate and potentially promote aortic insufficiency, which has led to a controversial debate on the appropriate surgical technique, especially for congenital bicuspid aortic valve disease. Desirable data on the time course of valve function and root dimensions for the alternative subcoronary technique comparing bicuspid and tricuspid aortic valve disease are scarce. Methods and Results-Echocardiographic examinations of 31 patients with congenital bicuspid aortic valve disease (group A; age 50.5Ϯ11.0 years) and 51 patients with acquired tricuspid aortic valve disease (group B; age 48.1Ϯ15.7 years) who were operated on between June 1994 and August 1998 were performed twice postoperatively. At first and second follow-up, respectively, maximum (mean) pressure gradients were 6.0Ϯ2.0 (3.6Ϯ1.0) and 5.1Ϯ2.1 (2.9Ϯ1.1) mm Hg in group A and 6.5Ϯ3.5 (3.9Ϯ1.9) and 5.0Ϯ1.7 (2.9Ϯ1.0) mm Hg in group B (PϾ0.05 between groups). In group A, grade 0 aortic insufficiency at first and second follow-up occurred in 8 and 7 patients, respectively, grade 0-I in 12 and 9 patients, grade I in 9 and 11 patients, grade I-II in 1 and 0 patients, and grade II in 1 and 4 patients; in group B, grade 0 aortic insufficiency occurred in 16 and 18 patients, grade 0-I in 16 and 8 patients, grade I in 17 and 21 patients, grade I-II in 0 and 1 patient, and grade II in 0 and 1 patient (PϾ0.05). Aortic insufficiency decreased in 10 patients (17%). However, there was an overall tendency for aortic insufficiency to increase over time (nϭ23, 38%), although it remained subclinical. Aortic root dimensions did not differ between groups and were constant during follow-up. Conclusions-This study provides some evidence that the function of the subcoronary pulmonary autograft in bicuspid aortic valve disease is excellent, with stable root dimensions, and is not different from that of tricuspid aortic valves at least up to 5.5 years postoperatively, which suggests the subcoronary technique should be reconsidered.

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Section: Discussionmentioning

confidence: 95%

Time Course of Aortic Valve Function and Root Dimensions After Subcoronary Ross Procedure for Bicuspid Versus Tricuspid Aortic Valve Disease

Schmidtke

Bechtel²,

Hueppe³

et al. 2001

Circulation

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“…18 Obviously, there exists a special risk for unphysiological dilatation of the pulmonary autograft after the Ross procedure in special cases which was not found when the subcoronary technique is used. 6 …”

Section: Dilatation Of the Aortic Rootmentioning

confidence: 99%

“…[2][3][4][5] Although the intermediate term results of this technique are excellent concern increases about the neoaortic root to sustain systemic pressure over time without dilatation and subsequent insufficiency. 6 Especially in patients with congenital aortic valve disease progressive dilatation was observed when complete root replacement was used. 6,7 This kind of risk is less inherent in the subcoronary and root inclusion techniques, however, the autograft needs to be adapted to the anatomy of the patient's aortic root rendering these techniques more susceptible to implantation related malfunction.…”

mentioning

confidence: 99%

“…6 Especially in patients with congenital aortic valve disease progressive dilatation was observed when complete root replacement was used. 6,7 This kind of risk is less inherent in the subcoronary and root inclusion techniques, however, the autograft needs to be adapted to the anatomy of the patient's aortic root rendering these techniques more susceptible to implantation related malfunction. Nevertheless, the obvious advantage of a lower risk of dilatation with these techniques that preserve the patient's aortic root is appealing, provided excellent results concerning the autograft can be achieved over time.…”

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Midterm Results of the Ross Procedure Preserving the Patient’s Aortic Root

Sievers

G²,

Graf³

et al. 2003

Circulation

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Background-Since the early 1990s, the pulmonary autograft is predominantly implanted as a freestanding root for less aortic valve regurgitation is reported. However, there is a certain risk of dilatation of the root over time potentially impairing valve function. We favor since 8 years the original subcoronary or inclusion technique to preserve the root of the patient as a restrain to dilatation. Methods and Results-Between June 1994 and May 2002 the subcoronary (nϭ228) and inclusion technique (nϭ17) were performed in 245 patients (191 male, 54 female), mean age 45.7Ϯ13.4 (15-70) years. The underlying aortic valve disease was an aortic insufficiency in nϭ83, stenosis in nϭ48, a combined aortic valve disease in nϭ111 and an acute endocarditis in nϭ19 patients. Previous aortic valve surgery was performed in nϭ23. Last follow-up investigations (within last year) including echocardiography was performed at a mean follow-up of 29.4Ϯ24.7 months (553.7 patient years). Hospital mortality was nϭ2, late mortality nϭ4 (all noncardiac). Two patients were lost to follow-up (99% complete clinical follow-up). Reoperations were necessary in nϭ7 valves (autograft: endocarditis nϭ1, malpositioning nϭ1, leaflet prolapse nϭ1; homograft: stenosis nϭ2, insufficiency nϭ2). Autograft insufficiency (AI) was AI 0 in nϭ154, AI I nϭ66, AI II nϭ8. The maximum/mean pressure gradient across the autograft was 6.6Ϯ3.4 (2.1 to 25.9)/3.6Ϯ1.8 (1.2 to 13.2) mm Hg, respectively. Homograft insufficiency was 0 in nϭ167, I in nϭ54, II in nϭ9, and III in nϭ1. Maximum and mean transhomograft pressure gradients were 11.7Ϯ6.8 (2.2 to 42.6)/6.2Ϯ3.8 (1.2 to 24.5) mm Hg. Most patients were NYHA class I (nϭ214), class II (nϭ19), class III (nϭ2). Significant aortic root dilatation was not observed. Conclusions-Aortic

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“…Die ursprüngliche subkoronare Implantationstechnik (Abbildung 11) ist in den letzten 10 Jahren in den meisten Zentren durch die komplette Wurzelersatztechnik abgelöst worden [40]. Die Autoren bevorzugen nach wie vor die Subkoronartechnik, um das Risiko der Aortenwurzelaneurysmabildung nach autologem Wurzelersatz zu minimieren [13,35]. Als Indikation kommen insbesondere Aortenvitien bei Kindern [17,18], Jugendlichen und jungen Erwachsenen, insbesondere Frauen mit Kinderwunsch, und Patienten mit hohen Anforderungen an die körperliche Belastbarkeit in Betracht.…”

Section: Ross-operationunclassified

Stellenwert von Aortenklappenrekonstruktion und Ross-Operation bei Aortenvitien

Sievers¹

2002

Herz

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Isolated reconstruction of the aortic valve such as decalcification, commissurotomy, plication of ring or leaflets of a tricuspid aortic valve and cusp extension are seldom indicated in contrast to the reconstruction of the bicuspid insufficient valve. Proper indication and skilled techniques lead to excellent hemodynamic and clinical intermediate-term result up to 7 years after reconstruction. Latest follow-up revealed a mean aortic insufficiency of 0.7, maximal pressure gradient of 11.4 +/- 8.5 mm Hg with zero hospital or late mortality, reoperation or thromboembolic events in 22 patients. The reconstructive techniques for aortic root aneurysm and/or type A dissection according to David or Yacoub have become routine procedures in the last 10 years. The hemodynamic and clinical results are excellent with low reoperation rate and very low risk of thromboembolism. Generally, a maximal diameter of the root of 5 cm is indicative for performing the operation. In patients with Marfan's syndrome the reconstruction should be advanced even with smaller diameters especially if these are progressive and combined with aortic insufficiency. ROSS-OPERATION: The Ross-Operation includes the replacement of the diseased aortic valve with the pulmonary autograft and reconstruction of the right ventricular outflow tract using a homograft. The hemodynamic results are excellent regarding the autograft and also the clinical results with very low thromboembolic risk and acceptable reoperation rate. This method is especially indicated for active young patients, women, who desire children, athletes and patients in general, who like to avoid long-term anticoagulation. In some cases the homograft may develop a dysfunction predominantly a pulmonary stenosis requiring reoperation. In the author's series of 245 Ross-operations in 12 years the homograft had to be replaced in 4 cases without letality. Innovative, decellularized homografts with the potential to repopulate with autologeous cells show promising results after 1 year of clinical implantation without signs of antibody development. Probably these tissue-engineered modification may improve the homograft results. The reconstructive techniques of the aortic valve and the Ross-operation have a certain risk of reoperation that must be weighed against the advantages of very low hospital and late valve related death, excellent hemodynamics, very low risk of macro- and microembolism as well as bleeding, lack of long-term anticoagulation and unrestricted life-style.

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Size and distensibility of the aortic root and aortic valve function after different techniques of the Ross procedure

Cited by 42 publications

References 18 publications

Time Course of Aortic Valve Function and Root Dimensions After Subcoronary Ross Procedure for Bicuspid Versus Tricuspid Aortic Valve Disease

Time Course of Aortic Valve Function and Root Dimensions After Subcoronary Ross Procedure for Bicuspid Versus Tricuspid Aortic Valve Disease

Midterm Results of the Ross Procedure Preserving the Patient’s Aortic Root

Stellenwert von Aortenklappenrekonstruktion und Ross-Operation bei Aortenvitien

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