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J Thorac Cardiovasc Surg 2005;130:212-213
© 2005 The American Association for Thoracic Surgery
Brief Communication |
Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany.
Received for publication October 7, 2004; accepted for publication November 23, 2004. * Address for reprints: Uwe Klima, MD, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany (Email: klima{at}thg.mh-hannover.de).
Aortic valve replacement using the pulmonary autograft as described by Ross1
in 1967 is an excellent permanent therapy for aortic valve disease, particularly in young patients. This procedure facilitates the omission of anticoagulation. The pulmonary autograft displays a superior longevity and excellent hemodynamic properties in combination with a low incidence of thromboembolism compared with all other aortic valve replacement procedures. However, its success is dictated by the suitability of the pulmonary autograft before the switch to the aortic position; a normal pulmonary valve (PV) without anatomic abnormalities is a prerequisite for the achievement of a satisfying operative and hemodynamic result.
We report on the postoperative outcome and midterm follow-up (4 years) of a 48-year-old female patient who underwent an aortic valve replacement with a quadricuspid pulmonary autograft. A quadricuspid PV is a rare anatomic feature with an incidence of 1 in 1100 individuals.2 To our knowledge, the use of a quadricuspid autograft in the Ross procedure has not been reported before.3
Clinical Summary
A 48-year-old female patient presented with signs of congestive heart failure such as peripheral edema and fatigue. Cardiac auscultation revealed a typical systolic murmur with punctum maximum in the third right intercostal space and projection into the carotid arteries. Angiography and echocardiography revealed good left ventricular function (left ventricular ejection fraction 60%) and severe left ventricular hypertrophy caused by advanced valvular stenosis with a calculated orifice area (aortic valve area) of 0.45 cm2 and increased transvalvular gradient of 121/84 mm Hg (peak/mean). The ascending aorta showed poststenotic dilation with a maximal diameter of 40 mm. The aortic root was normal with a diameter of 25 mm.
The patient underwent aortic autograft valve replacement. Preparation of the pulmonary and aortic valve was performed in a standard technique during cardiac arrest on extracorporeal circulation. After the pulmonary autograft was excised, a quadricuspid morphology became evident (PV), which was undetected before surgery. Vigorous irrigation tests demonstrated a patent PV without any sign of regurgitation. The autograft was implanted in a free-root replacement technique. The postoperative course was uneventful, and the patient was discharged on postoperative day 12 in excellent condition. Echocardiography performed intraoperatively and transthoracic echocardiography performed 1 month after surgery demonstrated a morphologically and functionally normal autograft.
Four years later, a routine follow-up echocardiography was performed in the clinically asymptomatic patient and revealed good left ventricular function with an ejection fraction of 65%. Although no recurrence of aortic stenosis was detectable, a second-degree aortic regurgitation (Figure 1) was evident in color Doppler echocardiography. The patient denied any symptoms, despite her physically demanding profession.
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Donald Ross1 introduced the use of the pulmonary autograft for aortic valve replacement in 1967. This technique allows the replacement of a diseased aortic valve with the autologous PV. Thus, systemic anticoagulation is circumvented, and the risk of thromboembolism or cerebral bleeding is negligible. In comparison with all other valve substitutes, the free-root technique shows the best hemodynamic outcome and consequently is the most frequently used approach.4 However, the normally tricuspid PV must be of regular anatomy and function. To our knowledge the use of a quadricuspid pulmonary autograft has not been described before. The early postoperative result with the quadricuspid autograft was promising. However, the development of autograft regurgitation of second degree (echocardiographic guidelines) as early as 4 years after surgical treatment identifies quadricuspid autografts as potentially problematic for this procedure. Preoperative echocardiographic evaluation of PV function and morphology are therefore mandatory.
References
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