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J Thorac Cardiovasc Surg 2007;133:190-195
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Pulmonary homograft muscle reduction to reduce the risk of homograft stenosis in the Ross procedure

^a Klinik für Herzchirurgie, Lübeck, Germany
^b Institut für Medizinische Biometrie und Statistik, Lübeck, Germany
^c Universitätsklinikum Schleswig-Holstein, Campus Lübeck, and the Klinik für Kardiologie, Helios Kliniken Schwerin, Lübeck, Germany.

Received for publication April 2, 2006; revisions received August 2, 2006; accepted for publication August 7, 2006.

^_* Address for reprints: Hans-H. Sievers, MD, Klinik für Herzchirurgie UKSH, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany. (Email: claudia.schmidtke{at}uni-luebeck.de).

OBJECTIVE: The Ross procedure has gained increasing interest as an attractive alternative for aortic valve replacement. Despite its advantages, there is a certain risk of structural valve deterioration, especially of the pulmonary homograft as a result of shrinkage and subsequent stenosis predominantly at the muscular annulus. Theoretically, reduction of homograft muscle tissue could reduce this risk.

METHODS: From February 1996 through December 2002, a total of 238 patients (mean age 44 ± 13.2 years) underwent the Ross procedure with the subcoronary technique with follow-up investigations before discharge and after 12 and 24 months. To estimate the importance of homograft muscle reduction within our institution-specific risk factor scale for change of transhomograft pressure gradient with time, we performed a generalized estimating equation approach, which identified homograft muscle reduction, higher body surface area in male patients, younger patient age, smaller homograft diameter, blood transfusions, and follow-up time as independent risk factors demonstrating a high ß value (–2.8638) for muscle reduction. To find out whether muscle reduction influences transhomograft pressure gradient, we compared patients with (group A, n = 39) and without (group B, n = 199) muscle reduction. The other mentioned independent risk factors were not different between groups, except for blood transfusions (group A greater than B, P < .01), indicating a negative bias for group A.

RESULTS: The maximum pressure gradient across the homograft was lower in patients with muscle reduction before discharge (4.5 ± 2.8 mm Hg group A vs 6.2 ± 3.8 mm Hg group B, P = .004) and after 1 (9.3 ± 5.8 vs 13.1 ± 8.4 mm Hg, P = .028) and 2 years (10.8 ± 7.6 vs 13.7 ± 7.5 mm Hg, P = .013). No significant differences were found concerning homograft insufficiency.

CONCLUSIONS: We provide some evidence that transhomograft pressure gradient can be reduced significantly within the first 2 years after operation by homograft muscle reduction. Longer term follow-up is necessary to evaluate this promising operative technique further.