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Thompson SE, Prabhakar CRK, Creasey T, Stoll VM, Gurney L, Green J, Fox C, Morris RK, Thompson PJ, Thorne SA, Clift P, Hudsmith LE. Pregnancy outcomes in women following the Ross procedure. Int J Cardiol 2023; 371:135-139. [PMID: 36181953 DOI: 10.1016/j.ijcard.2022.09.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The Ross procedure, where a pulmonary autograft (neoaorta) replaces the aortic valve, has excellent long-term outcomes in patients with congenital aortic valve disease. However, there are reports of neoaortic dilatation and dissection. An increasing number of women are wishing to become pregnant following the Ross procedure, but little is known about the occurrence and risks of neoaortic dilatation and complications in pregnancy. We investigated neoaorta function and outcomes in pregnancy following the Ross procedure. METHODS This retrospective study investigated women post-Ross procedure at a tertiary ACHD unit between 1997 and 2021. Imaging evaluated neoaortic root dimensions and regurgitation pre-, and post- pregnancy, compared with matched non-pregnant controls. Primary endpoints were change in neoaortic dimensions, degree of regurgitation and adverse maternal outcomes. RESULTS Nineteen pregnancies in 12 women were included. The mean change in neoaortic root diameter post-pregnancy was 1.8 mm (SD 3.4) (p = 0.017). There was no significant change in neoaortic dimensions in matched controls during follow-up. There were no cases of dissection, arrhythmia, acute coronary syndrome, or maternal mortality. Three deliveries were pre-term, including one emergency Caesarean section due to maternal cardiac decompensation, requiring aortic root replacement post-partum but there were no neonatal deaths. CONCLUSIONS Pregnancy following the Ross procedure is associated with neoaortic dilatation, and pregnancy is generally well tolerated. Although adverse maternal outcomes are uncommon, there are still rare cases of cardiac complications in and around the time of pregnancy. These findings emphasise the need for accessible pre-pregnancy counselling, risk stratification and careful surveillance through pregnancy by specialist cardio-obstetric multi-disciplinary teams.
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Affiliation(s)
- Sophie E Thompson
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK.
| | | | - Tristan Creasey
- Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Victoria M Stoll
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Leo Gurney
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jennifer Green
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK
| | - Caroline Fox
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - R Katie Morris
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK; Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Peter J Thompson
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Sara A Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Canada
| | - Paul Clift
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK
| | - Lucy E Hudsmith
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK
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Van Hoof L, Verbrugghe P, Jones EAV, Humphrey JD, Janssens S, Famaey N, Rega F. Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts. Front Cardiovasc Med 2022; 9:829120. [PMID: 35224059 PMCID: PMC8865563 DOI: 10.3389/fcvm.2022.829120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
The Ross, or pulmonary autograft, procedure presents a fascinating mechanobiological scenario. Due to the common embryological origin of the aortic and pulmonary root, the conotruncus, several authors have hypothesized that a pulmonary autograft has the innate potential to remodel into an aortic phenotype once exposed to systemic conditions. Most of our understanding of pulmonary autograft mechanobiology stems from the remodeling observed in the arterial wall, rather than the valve, simply because there have been many opportunities to study the walls of dilated autografts explanted at reoperation. While previous histological studies provided important clues on autograft adaptation, a comprehensive understanding of its determinants and underlying mechanisms is needed so that the Ross procedure can become a widely accepted aortic valve substitute in select patients. It is clear that protecting the autograft during the early adaptation phase is crucial to avoid initiating a sequence of pathological remodeling. External support in the freestanding Ross procedure should aim to prevent dilatation while simultaneously promoting remodeling, rather than preventing dilatation at the cost of vascular atrophy. To define the optimal mechanical properties and geometry for external support, the ideal conditions for autograft remodeling and the timeline of mechanical adaptation must be determined. We aimed to rigorously review pulmonary autograft remodeling after the Ross procedure. Starting from the developmental, microstructural and biomechanical differences between the pulmonary artery and aorta, we review autograft mechanobiology in relation to distinct clinical failure mechanisms while aiming to identify unmet clinical needs, gaps in current knowledge and areas for further research. By correlating clinical and experimental observations of autograft remodeling with established principles in cardiovascular mechanobiology, we aim to present an up-to-date overview of all factors involved in extracellular matrix remodeling, their interactions and potential underlying molecular mechanisms.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Jay D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Bichell DP. Autograft Root Dilation After the Ross Procedure Is Not Benign. World J Pediatr Congenit Heart Surg 2021; 12:516-517. [PMID: 34278869 DOI: 10.1177/21501351211015927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Autograft root dilation is common after the unsupported Ross procedure. In the absence of valvar incompetence, and with the perception that dissection is exceedingly rare, expectant management of autograft aneurysm is common practice. Autograft dissection may not be as rare as thought though, as at this point 7 case reports have accrued that describe autograft dissection requiring urgent operative intervention. All had a bicuspid native aortic valve. Bicuspid aortic valve has been shown to be associated with an intrinsic, histologically demonstrated pulmonary arteriopathy, possibly contributing to autograft root dilation and dissection. Autograft root dilation can no longer be regarded as benign, especially in patients with bicuspid aortic valve. Mounting evidence further validates the practice of externally supporting the Ross autograft. For patients who have had an unsupported Ross procedure, mounting evidence may support earlier intervention for autograft root dilation and aneurysm.
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Affiliation(s)
- David P Bichell
- Department of Cardiac Surgery, Monroe Carell, Jr. Children's Hospital, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Fallot Tetralogy with Dissected Pulmonary Artery Aneurysm: A Rare Case Report. Ann Vasc Surg 2020; 68:568.e7-568.e10. [PMID: 32278868 DOI: 10.1016/j.avsg.2020.03.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/25/2020] [Accepted: 03/28/2020] [Indexed: 11/22/2022]
Abstract
Pulmonary artery dissection is a rare and extremely dangerous disease with high mortality rates. It is one of the most serious complications of chronic pulmonary hypertension. It may be related to chronic pulmonary hypertension and pulmonary artery dilatation. Early diagnosis of pulmonary dissection is particularly important because of its high mortality. Once the symptoms worsen or severe deterioration of the disease occurs, imaging examination should be performed promptly for early diagnosis and timely treatment.
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Peeters G, Arrigoni SC, Schoof P, Accord RE, Mariani MA. Acute Type A Dissection 18 Years After a Ross Operation: The Old Prejudice. Ann Thorac Surg 2019; 107:e255-e257. [DOI: 10.1016/j.athoracsur.2018.08.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/20/2018] [Indexed: 11/28/2022]
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Myers MR, Magruder JT, Crawford TC, Grimm JC, Halushka MK, Baumgartner WA, Cameron DE. Surgical repair of aortic dissection 16 years post-Ross procedure. J Surg Case Rep 2016; 2016:rjw059. [PMID: 27141044 PMCID: PMC4852982 DOI: 10.1093/jscr/rjw059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The Ross procedure is an excellent choice for younger patients in need of aortic valve replacement. While patients have benefited from superior survival rates associated with this procedure, complications related to aortic root dilatation and degeneration of the autograft may be encountered later in life. These challenges may be exacerbated in those with underlying connective tissue abnormalities, a phenomenon commonly observed in the bicuspid aortic valve population. In this report, we present the case of a patient who presented with an aortic dissection 16 years after a Ross procedure for aortic insufficiency in the setting of a bicuspid aortic valve, and review the existing literature related to this adverse event.
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Affiliation(s)
- Mollie R Myers
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Trent Magruder
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd C Crawford
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua C Grimm
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marc K Halushka
- Department of Pathology, Division of Cardiovascular Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William A Baumgartner
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Duke E Cameron
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA,
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Rabkin DG, Reid BB, Doty JR. Acute on chronic pulmonary autograft dissection. Interact Cardiovasc Thorac Surg 2014; 20:563-4. [DOI: 10.1093/icvts/ivu427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Hostiuc S, Dermengiu D, Ceauşu M, Capatina CO, Luca L, Hostiuc M. Sudden death due to dissection of the thoracic aorta associated with dissection and rupture of the pulmonary artery: Report of two cases. Forensic Sci Int 2014; 236:e9-13. [DOI: 10.1016/j.forsciint.2013.12.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
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Stelzer P. The Ross procedure: state of the art 2011. Semin Thorac Cardiovasc Surg 2012; 23:115-23. [PMID: 22041040 DOI: 10.1053/j.semtcvs.2011.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2011] [Indexed: 11/11/2022]
Abstract
The purpose of this paper is to review the current literature and practice of the Ross concept of using the autologous pulmonary valve to replace a diseased aortic valve. The potential advantages and disadvantages of these operations will be evaluated in the context of alternative options and relative risks. The different surgical techniques of subcoronary and full root methods will be discussed and important technical aspects reviewed. Long-term outcomes will be described to the extent these are available, including recent publications describing a survival advantage for the Ross. Brief discussions will be presented regarding hemodynamics, child-bearing, endocarditis, and the use of the Ross in pediatric patients as well as biological adaptability of the living pulmonary autograft.
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Affiliation(s)
- Paul Stelzer
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York 10029, USA.
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Juthier F, Banfi C, Vincentelli A, Ennezat PV, Le Tourneau T, Pinçon C, Prat A. Modified Ross operation with reinforcement of the pulmonary autograft: Six-year results. J Thorac Cardiovasc Surg 2010; 139:1420-3. [PMID: 20381090 DOI: 10.1016/j.jtcvs.2010.01.032] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 01/02/2010] [Accepted: 01/22/2010] [Indexed: 11/29/2022]
Affiliation(s)
- Francis Juthier
- Centre Hospitalier Régional et Universitaire de Lille, Pôle de Chirugie Cardio-vasculaire, 59037 Lille, France
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Luciani GB, Viscardi F, Pilati M, Prioli AM, Faggian G, Mazzucco A. The Ross–Yacoub procedure for aneurysmal autograft roots: A strategy to preserve autologous pulmonary valves. J Thorac Cardiovasc Surg 2010; 139:536-42. [DOI: 10.1016/j.jtcvs.2009.08.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 06/18/2009] [Accepted: 08/10/2009] [Indexed: 12/01/2022]
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Elkins RC, Thompson DM, Lane MM, Elkins CC, Peyton MD. Ross operation: 16-year experience. J Thorac Cardiovasc Surg 2008; 136:623-30, 630.e1-5. [PMID: 18805263 DOI: 10.1016/j.jtcvs.2008.02.080] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2005] [Revised: 10/29/2007] [Accepted: 02/25/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We performed a review of a consecutive series of 487 patients undergoing the Ross operation to identify surgical techniques and clinical parameters that affect outcome. METHODS We performed a prospective review of consecutive patients from August 1986 through June 2002 and follow-up through August 2004. Patient age was 2 days to 62 years (median, 24 years), and 197 patients were less than 18 years of age. The Ross operation was performed as a scalloped subcoronary implant in 26 patients, an inclusion cylinder in 54 patients, root replacement in 392 patients, and root-Konno procedure in 15 patients. Clinical follow-up in 96% and echocardiographic evaluation in 77% were performed within 2 years of closure. RESULTS Actuarial survival was 82% +/- 6% at 16 years, and hospital mortality was 3.9%. Freedom from autograft failure (autograft reoperation and valve-related death) was 74% +/- 5%. Male sex and primary diagnosis of aortic insufficiency (no prior aortic stenosis) were significantly associated with autograft failure by means of multivariate analysis. Freedom from autograft valve replacement was 80% +/- 5%. Freedom from endocarditis was 95% +/- 2%. One late thromboembolic episode occurred. Freedom from allograft reoperation or reintervention was 82% +/- 4%. Freedom from all valve-related events was 63% +/- 6%. In children survival was 84% +/- 8%, and freedom from autograft valve failure was 83% +/- 6%. CONCLUSIONS The Ross operation provides excellent survival in adults and children willing to accept a risk of reoperation. Male sex and a primary diagnosis of aortic insufficiency had a negative effect on late results.
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Affiliation(s)
- Ronald C Elkins
- Department of Surgery, Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla 73190, USA.
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Schoof PH, Takkenberg JJM, van Suylen RJ, Zondervan PE, Hazekamp MG, Dion RAE, Bogers AJJC. Degeneration of the pulmonary autograft: An explant study. J Thorac Cardiovasc Surg 2006; 132:1426-32. [PMID: 17140971 DOI: 10.1016/j.jtcvs.2006.07.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 06/26/2006] [Accepted: 07/12/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to determine the histologic features of pulmonary autografts explanted after the Ross operation. METHODS Histologic sections of 30 explanted autografts and 8 normal heart valves were compared and semiquantitatively scored by a blinded cardiovascular pathologist. RESULTS Pulmonary autografts (n = 30) were explanted on average 6.1 +/- 0.6 years (median, 6.6 years; range, 0.1-11.7 years) after the Ross operation (n = 28) or removed at autopsy (n = 2). Twelve (43%) of the patients undergoing reoperation had no or negligible autograft insufficiency on early transthoracic echocardiography, 12 (43%) had grade 1 autograft insufficiency, and 4 (14%) had grade 1-2 autograft insufficiency. Valve regurgitation with root dilatation was the most common indication for reoperation after root replacement (n = 26 [93%]) and regurgitation after subcoronary implanted autografts (n = 2 [7%]). Microscopy of the autograft explants revealed normal laminar architecture and cellularity. Wall specimens were characterized by reduced and fragmented elastin and increased collagen levels (fibrosis). Medial elastin changes were associated with the presence of hypertrophic smooth muscle cells. Fibrosis was most severe in the adventitia. Intimal thickening was a common finding. Valve explants showed significant thickening caused by fibrocellular tissue on the ventricular surface and marked thickening of the free margin. An autopsy explant with normal function before death showed similar features. CONCLUSIONS Pulmonary autograft explants showed severe aneurysmal degeneration of the wall, which was characterized by intimal thickening, medial elastin fragmentation, and adventitial fibrosis. Valve leaflets were thickened. The presence of these features in a nonfailing explant suggests these changes represent a common mode of remodeling.
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Affiliation(s)
- Paul H Schoof
- Department of Cardiothoracic Surgery, University Medical Center Leiden, Leiden, The Netherlands.
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Abstract
PURPOSE OF REVIEW Autograft root pathology is the most common adverse event late after the Ross operation. Therefore, characterization of prevalence, risk factors and natural history of root disease, as well as identification of preventive and therapeutic strategies, is warranted. RECENT FINDINGS Autograft root pathology affects up to one third of long-term survivors of the Ross operation. Root replacement technique and preoperative aortic aneurysm are recurrent risk factors. Any age group, except for infants, may be affected. Dilatation is often progressive leading to valve regurgitation, true aneurysm, and, rarely, dissection. Primary prevention involves avoidance of root technique, graft repalcement of aneurysmal aorta, or modifications of the root technique. Use of beta-receptor antagonist or angiotensin converting enzyme-inhibitors for secondary prevention is still empirical. Indications to resection of root aneurysm are based on maximum root area indexed to body height. Reintervention prior to appearance of relevant valve insufficiency increases likelihood of pulmonary valve preservation. Definition of functional outcome after autograft valve-sparing procedures needs longer follow-up. SUMMARY Over a decade after worldwide embracement of the root replacement technique for the Ross procedure, autograft root pathology is emerging as a prevalent complication. Prophylactic and therapuetic strategies are proposed to mitigate the current and future impact of this phenomenon.
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