J Thorac Cardiovasc Surg 2004;127:1225
© 2004 The American Association for Thoracic Surgery
Mitral valve replacement by a Gore-Tex reinforced pulmonary autograft in a child
Emin Tireli, MDa,
Gürkan Çetin, MDb,
lksen Söyler, MDa,
Ahmet Özkara, MDb
a Department of Cardiovascular Surgery, Istanbul Medical School, Uskudar-Istanbul, Turkey
b Department of Cardiovascular Surgery, Institute of Cardiology, Istanbul University, Uskudar-Istanbul, Turkey
To the Editor:
We read the interesting case report entitled "Mitral valve replacement by a Gore-Tex reinforced pulmonary autograft in a child" in the October issue of the Journal.1 The Ross II procedure is not widely used in cardiac surgical practice because of the technical difficulties. There are also many arguments concerning this procedure.2 There might be complications such as constriction and deformation on the mitral position of the pulmonary autograft. Therefore, lengthwise and crosswise reinforcements of the pulmonary autografts might be needed. The procedure is possible with the use of Dacron or polytetrafluoroethylene (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz) grafts.
For pediatric patients with a small mitral annulus, the Ross II procedure is indicated. We performed the Ross II procedure in a child with congenital mitral insufficiency and endocarditis. The mitral leaflets were totally deformed, so we resected them. The mitral annulus was 14 mm in diameter. We decided to replace the mitral valve with a pulmonary autograft because of the endocarditis and the absence of an adequately sized mechanical mitral valve prosthesis. After the pulmonary autograft was harvested, it was introduced into the 14-mm diameter soft Dacron tube graft by the same method that the authors used. Because the left atrium was very large, a Dacron graft carrying the pulmonary autograft was sutured to the mitral annulus by using the "top hat" technique.3 However, perioperative transesophageal echocardiography performed after cardiopulmonary bypass revealed a 25 mm Hg transmitral gradient. We decided to reinstitute cardiopulmonary bypass and reevaluate the composite pulmonary autograft. After cardioplegic arrest, the left atrium was reopened, and the Dacron graft was found to be constricted and deformed. Therefore the Dacron graft was replaced with a 14-mm diameter polytetrafluoroethylene (Gore-Tex) tube graft. This time there was no significant transmitral gradient.
We believe that stiff Dacron grafts used for the reinforcement of pulmonary autografts may yield better results than soft ones. We recommend the use of polytetrafluoroethylene (Gore-Tex) tube grafts in the Ross II procedure instead of the Dacron grafts that Yamagushi and colleagues1 used.
- Yamagishi M, Shuntoh K, Matsushita T, Fujiwara K, Shinkawa T, Miyazaki T, et al. Mitral valve replacement by a Gore-Tex reinforced pulmonary autograft in a child. J Thorac Cardiovasc Surg. 2003;126:12181219[Free Full Text]
- Kabbani SS, Jamil H, Hammound A, Nabhani F, Hariri R, Sabbagh N, et al. Use of the pulmonary autograft for mitral replacement: short- and medium-term experience. Eur J Cardiothorac Surg. 2001;20:257261[Abstract/Free Full Text]
- Ross DN, Kabbani S. Mitral valve replacement with pulmonary autograft: the mitral top hat. J Heart Valve Dis. 1997;6:542545[Medline]