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J Thorac Cardiovasc Surg 2005;130:1215-1216
© 2005 The American Association for Thoracic Surgery
Brief Communication |
Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
Received for publication June 12, 2005; accepted for publication June 20, 2005. * Address for reprints: Aschraf El-Essawi, MD, Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Salzdahlumer Strasse 90, 38126 Braunschweig, Germany (Email: aelessawi{at}aol.com).
As the Ross operation is gaining popularity, reinterventions for autograft failure are gaining importance. Patients with this problem are usually younger adults who would be facing lifelong anticoagulation if the autograft were to be replaced with a mechanical conduit. On the other hand, a biologic valve is not a suitable alternative. Because many of these patients have macroscopically normal or nearly normal valve leaflets, a valve-sparing root reimplantation appears most suited to meet their need for a reintervention that would maintain the promised benefits of the initial Ross procedure. These are the lack of a need for anticoagulation, nearly physiologic hemodynamics, and presumed longevity of repair, provided that the long-term results are comparable to those of root reimplantation for aneurysms of the ascending aorta. We report a case of autograft failure 4 years after a Ross operation that was successfully managed by valve-sparing root reimplantation and concomitant leaflet reconstruction.
Clinical Summary
A 33-year old man who had undergone a Ross operation with a subcoronary implantation technique because of an incompetent bicuspid aortic valve 4 years previously was seen with a moderate to severe insufficiency of the autograft. Follow-up echocardiography had shown signs of progressive volume overload, with a left ventricular diastolic dimension of 62 mm, a left ventricular systolic dimension of 43 mm, and a left atrial dimension of 38 mm, as well as a mild reduction of the ejection fraction (50%). The aortic root had a diameter of 35 mm. Clinically, the patient was in New York Heart Association functional class II. Because of his young age and previous Ross operation, the mutual decision (the patient himself was a physician) was for a valve-sparing operation.
Intraoperatively, we found a subcoronary positioned autograft with two tears of 2 mm at the inflow suture line, which had led to a paravalvular leakage. One tear lay between the right coronary and noncoronary commissures and the other between the right and left coronary commissures. In addition, there was a minute hole in the base of the left coronary leaflet and a 2-mm long hole close to the free margin of the left coronary leaflet. A valve-sparing procedure (reimplantation technique David I) was performed with a 28-mm Dacron polyester fabric graft and reconstruction of the leaflets with 7-0 interrupted Prolene sutures (Ethicon, Inc, Somerville, NJ). A remaining mild prolapse of the left coronary leaflet was corrected by a triangular plication of the free margin with interrupted 5-0 Prolene sutures. Intraoperative transesophageal echocardiography revealed no residual valve insufficiency and no paravalvular leakage.
The remaining hospital stay was uneventful. The patient was discharged on the sixth postoperative day. At the first follow-up at 1 month, the patient was free of symptoms (New York Heart Association functional class 0), with echocardiography showing a left ventricular diastolic dimension of 50 mm, a left ventricular systolic dimension of 36 mm, and an ejection fraction of 60%. The valve was completely competent, and the valve gradient was measured at a mean of 9 mm Hg. At the last communication at 21 postoperative months, the patient remained symptom free (New York Heart Association functional class 0), and echocardiography showed a stable valve function (aortic insufficiency grade 0-I).
Discussion
Although short-term results appear to confirm this procedure as a good choice, long-term follow-up in the literature is lacking. Leyh and colleagues
1
were the first to report on a valve-sparing root reimplantation after a Ross operation because of autograft dilatation and concomitant valve insufficiency. At 14 postoperative months, the autograft showed normal valve function with no signs of regurgitation or stenosis.
Masetti and associates,
2
reporting on a patient similar to that of Leyh and colleagues
1
but instead choosing the remodeling technique for sparing the valve, mentioned that their patient was free of symptoms and of regurgitation at 6 months of follow-up. Ishizaka and associates
3
reported similar results with a similar follow-up in 4 patients in whom they preserved the valve with a root-remodeling technique.
When one considers that the Ross procedure is chosen for its promise of lack of anticoagulation, near-physiologic hemodynamics, and longevity of repair, valve-sparing operations appear well-suited to a compatible promise at reoperation. This is especially true if long-term outcomes prove to be similar to those seen after valve-sparing operations in patients with aortic aneurysms and aortic regurgitation.
Although the Ross operation has gained popularity, the number of patients undergoing similar reoperative procedures in a single center will remain small for some time. As a result, we see an important role of similar case reports in establishing a better understanding of this problem and how best to deal with it.
References
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