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J Thorac Cardiovasc Surg 2003;125:738-739
© 2003 The American Association for Thoracic Surgery

Letters to the Editor

The Ross operation as an ideal choice for aortic valve replacement in patients with congenital disease

La Timone Children's Hospital, Pediatric Cardiac Surgery, 264, rue St Pierre, Marseille BDR 13005, France

To the Editor:

We read with interest the article by Al-Halees and associates ¹ concerning the Ross procedure for congenital aortic valve disease, and we congratulate them for their valuable work.

They treated 53 patients with congenital heart disease aged 3 months to 18 years (median 9 years). Ten patients were younger than 2 years of age. The mean cardiopulmonary bypass time was 109 ± 36 minutes (52-243 minutes) with a mean crossclamping time 79.5 minutes (45-164 minutes).

The mean follow-up was 4 years with 3 hospital deaths, all among patients with subaortic stenosis. One patient needed autograft replacement for endocarditis. A right ventricular outflow tract gradient necessitated balloon dilatation in 2 and reoperation in 1. All patients but 1 have normal or near-normal autograft valve function. The homografts in the pulmonary position demonstrated gradients in 14 patients; 9 gradients were less than 35 mm Hg and 5 greater than 50 mm Hg. Three of the patients underwent reoperation.

We have a similar group of 26 patients (age range 2.5 months-12 years, median 6.9 years, 5 < 1 year; weight range 4.9-42 kg, median 23.6 kg, 7 < 10 kg) having the Ross operation for congenital aortic valve disease: aortic stenosis in 24 and congenital insufficiency in 2. Twelve patients had additional malformations: subaortic stenosis in 7, coarctation of the aortic isthmus in 2, mitral insufficiency in 2, and ventricular septal defect in 1. Thirteen patients had a prior operation: aortic valvotomy in 11, balloon dilatation in 4, coarctation repair in 2, and aortic root replacement by a homograft in 1.

We used the widest possible pulmonary homografts in all patients. Concomitant surgical procedures were performed in 9 patients: 2 mitral valve repairs, 2 resections of a subaortic membrane, and 5 Konno repairs for subaortic stenosis (cardiopulmonary bypass time 114-162 minutes, median 137.3 minutes; aortic crossclamping time 97-143 minutes, median 123.1 minutes for autograft preparation and implantation and homograft implantation).

There were no hospital deaths but 2 instances of delayed sternal closure and 1 pacemaker implantation. During follow-up (1-8 years, median 4.1 years), there was 1 late death during reoperation for false aortic aneurysm of the proximal anastomosis 6 months postoperatively. One patients had a modified Konno procedure for subaortic stenosis (infundibulotomy with a vertical incision in the subannular left ventricular outflow tract and patch repair). Minimal aortic insufficiency is present in 7 patients, and 4 patients have asymptomatic gradients on the homograft (20-35 mm Hg). Al-Halees and associates did not explain the conduct and short duration of cardiopulmonary bypass (minimum 52 minutes with 45 minutes of aortic clamping), which are different from most related publications. ^2,3

One of the differences between their results and ours is that the hospital mortality is confined to patients with left ventricular outflow tract obstruction (the total number with involvement of the outflow tract is not mentioned), making their surgical technique for relief of outflow tract obstruction questionable. Another difference is the right ventricular outflow tract gradient in 25% (more than 50 mm Hg in 9%) of their patients despite the use of immunosuppressive therapy. We think our result is due to the use of pulmonary homografts. Despite these differences in results, both studies confirm that the Ross operation represents the best choice for aortic valve replacement in infants and children.

References

1. Al-Halees Z, Pieters F, Qadoura F, Shahid M, Al-Amri M, Al-Fadley F. The Ross procedure is the procedure of choice for congenital aortic valve disease. J Thorac Cardiovasc Surg. 2002;123:437-42.[Abstract/Free Full Text]
   
2. Laudito A, Brook M, Suleman S, Bleiweis M, Thompson L, Hanley F, et al. The Ross procedure in children and young adults: a word of caution. J Thorac Cardiovasc Surg. 2001;122:147-53.[Abstract/Free Full Text]
   
3. Ohye R, Gomez C, Ohye B, Goldberg C, Bove E. The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function. Ann Thorac Surg. 2001;72:823-30.[Abstract/Free Full Text]
   
4. Metras D, Kreitmann B, Riberi A, Samir K, Fraisse A. Operation de Ross chez l'enfant et l'adolescent; à propos de 24 cas. Arch Mal Coeur. 2001;94(suppl 1:)30.
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Khaled Samir Alberto Riberi Bernard Kreitmann Dominique Metras Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Samir, K. Articles by Metras, D. Search for Related Content PubMed PubMed Citation Articles by Samir, K. Articles by Metras, D.