J Thorac Cardiovasc Surg 2002;124:418
© 2002 The American Association for Thoracic Surgery
Reply
Thoralf M. Sundt, MD
Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905
Reply to the Editor:
My coauthors and I appreciate Dr Stelzer's interest in our recent case demonstrating dilatation of a pulmonary autograft implanted as a freestanding root replacement. Dr Stelzer makes a cogent argument against using the native root to reinforce the autograft. Indeed, a dilated native root may not provide the necessary support. The difficulty is that without more data we cannot be sure that patients with a normal sized root at surgery are free of the risk of late dilation of their autografts. Regurgitation may be a marker for dilatation, as Dr Stelzer suggests; however, aneurysmal dilatation of the aorta in bicuspid aortic valve disease may be associated with either stenosis or regurgitation and may even occur in the absence of hemodynamically significant functional valve disease. The relative roles of hemodynamic stress and underlying structural abnormalities of the great vessel wall continue to be debated and are the subject of current clinical and laboratory investigations in our laboratory as well as those of others. The advent of genomic technologies for the analysis of tissue transcriptomes offers new approaches to this century-old question.
In the meantime, as Dr Stelzer says, "the real question is in whom and how best to support the autograft." Dr Stelzer has provided us with a number of interesting options and we are indebted to him for sharing with us his considerable experience. We believe that the important point for those who perform the Ross autograft operation is to recognize late dilatation as a potential issue, to provide ongoing surveillance for this complication, and to continue to explore possible solutions. Indeed, a Dacron jacket may prove a durable solution. The prospect of reoperating on an autograft so attired is, however, unappealing.
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