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J Thorac Cardiovasc Surg 2000;119:210-220
© 2000 Mosby, Inc.

SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE

DILATION OF THE PULMONARY AUTOGRAFT AFTER THE ROSS PROCEDURE

From the Divisions of Cardiovascular Surgery and Cardiology of Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.

Address for reprints: Tirone E. David, MD, 200 Elizabeth St—13EN219, Toronto, Ontario, Canada M5G 2C4 (E-mail: tdavid{at}torhosp.toronto.on.ca) .

Objective: Dilation of pulmonary autograft after the Ross procedure is being recognized with increasing frequency. This study was undertaken to examine the extent of this problem and factors that may be associated with it.
Methods: The clinical, operative, and echocardiographic data of 118 patients who underwent the Ross procedure were reviewed. The mean age of 79 men and 39 women was 34 ± 9 years, range 17 to 57 years. Bicuspid or other congenital aortic valve disease was present in 81% of patients. The pulmonary autograft was sutured as a valve in the subcoronary position in 2 patients, as a root inside of the aortic root in 45, and was used for complete aortic root replacement in 71. Teflon felt was not used to buttress the proximal or the distal anastomosis of the pulmonary autograft. The diameters of the sinuses of Valsalva, aortic anulus, and sinotubular junction were measured early and late after the operation with echocardiography. The mean follow-up was 44 months.
Results: The diameter of the sinuses of Valsalva increased from 31.4 ± 0.4 mm to 33.7 ± 0.5 mm (P = .01). Analysis of covariance revealed a significant change over time in this diameter, as well as a difference between operative techniques, with replacement of the aortic root being associated with a higher risk of dilation (P = .0006). In 13 patients the diameter ranged from 40 to 51 mm. The diameter of the aortic anulus decreased in most patients and increased in 15, but there was no interaction between these changes and the operative technique. The diameter of the sinotubular junction increased in patients who had aortic root replacement and decreased in patients who had aortic root inclusion (P = .007). Moderate aortic insufficiency developed in 7 patients, and 3 required replacement of the pulmonary autograft. All patients with moderate aortic insufficiency had dilation of the aortic anulus and/or sinotubular junction.
Conclusions: Dilation of the pulmonary autograft after the Ross procedure may occur because of an intrinsic abnormality of the pulmonary root in patients with congenital aortic valve disease. The technique of aortic root replacement is associated with a higher risk of dilation of the sinuses of Valsalva and sinotubular junction than the technique of aortic root inclusion.

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				G. B. Luciani, L. Barozzi, A. Tomezzoli, G. Casali, and A. Mazzucco Bicuspid aortic valve disease and pulmonary autograft root dilatation after the Ross procedure: A clinicopathologic study J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 74 - 79. [Abstract] [Full Text] [PDF]

				A. Laudito, M. M. Brook, S. Suleman, M. S. Bleiweis, L. D. Thompson, F. L. Hanley, and V. M. Reddy The Ross procedure in children and young adults: A word of caution J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 147 - 153. [Abstract] [Full Text] [PDF]

				T. Walker, M. K. Heinemann, W. Schneider, M. Wehrmann, B. Bultmann, and G. Ziemer Early failure of the autograft valve after the Ross procedure J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 187 - 188. [Full Text] [PDF]

				R. Pessotto, W. J. Wells, C. J. Baker, C. Luna, and V. A. Starnes Midterm results of the Ross procedure Ann. Thorac. Surg., May 1, 2001; 71 (2007): S336 - S339. [Abstract] [Full Text] [PDF]

				J. J.M. Takkenberg, M. J.C. Eijkemans, L. A. van Herwerden, E. W. Steyerberg, G. L. Grunkemeier, J. D. F. Habbema, and A. J.J.C. Bogers Estimated event-free life expectancy after autograft aortic root replacement in adults Ann. Thorac. Surg., May 1, 2001; 71 (2007): S344 - S348. [Abstract] [Full Text] [PDF]

				P. H. Schoof, A. C. Gittenberger-de Groot, E. de Heer, J. A. Bruijn, M. G. Hazekamp, and H. A. Huysmans Remodeling of the porcine pulmonary autograft wall in the aortic position J. Thorac. Cardiovasc. Surg., July 1, 2000; 120(1): 55 - 65. [Abstract] [Full Text] [PDF]

				C. J. Knott-Craig, R. C. Elkins, K. Santangelo, C. McCue, and M. M. Lane Aortic valve replacement: comparison of late survival between autografts and homografts Ann. Thorac. Surg., May 1, 2000; 69(5): 1327 - 1331. [Abstract] [Full Text] [PDF]