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Kim JY, Cho WC, Kim DH, Choi ES, Kwon BS, Yun TJ, Park CS. Outcomes after Mechanical Aortic Valve Replacement in Children with Congenital Heart Disease. J Chest Surg 2023; 56:394-402. [PMID: 37696780 PMCID: PMC10625956 DOI: 10.5090/jcs.23.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 09/13/2023] Open
Abstract
Background The optimal choice of valve substitute for aortic valve replacement (AVR) in pediatric patients remains a matter of debate. This study investigated the outcomes following AVR using mechanical prostheses in children. Methods Forty-four patients younger than 15 years who underwent mechanical AVR from March 1990 through March 2023 were included. The outcomes of interest were death or transplantation, hemorrhagic or thromboembolic events, and reoperation after mechanical AVR. Adverse events included any death, transplant, aortic valve reoperation, and major thromboembolic or hemorrhagic event. Results The median age and weight at AVR were 139 months and 32 kg, respectively. The median follow-up duration was 56 months. The most commonly used valve size was 21 mm (14 [31.8%]). There were 2 in-hospital deaths, 1 in-hospital transplant, and 1 late death. The overall survival rates at 1 and 10 years post-AVR were 92.9% and 90.0%, respectively. Aortic valve reoperation was required in 4 patients at a median of 70 months post-AVR. No major hemorrhagic or thromboembolic events occurred. The 5- and 10-year adverse event-free survival rates were 81.8% and 72.2%, respectively. In univariable analysis, younger age, longer cardiopulmonary bypass time, and smaller valve size were associated with adverse events. The cut-off values for age and prosthetic valve size to minimize the risk of adverse events were 71 months and 20 mm, respectively. Conclusion Mechanical AVR could be performed safely in children. Younger age, longer cardiopulmonary bypass time and smaller valve size were associated with adverse events. Thromboembolic or hemorrhagic complications might rarely occur.
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Affiliation(s)
- Joon Young Kim
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Chul Cho
- Department of Thoracic and Cardiovascular Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Dong-Hee Kim
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Seok Choi
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Sang Kwon
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Jin Yun
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chun Soo Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Tohme S, Jiang S, Farooqi K, Crystal MA, Blitzer D, Ferrari G, Bacha E, Kalfa D. Ross Procedure in Neonate and Infant Populations: A Meta-Analysis Review. World J Pediatr Congenit Heart Surg 2022; 13:759-769. [DOI: 10.1177/21501351221119494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective This study aims to perform a meta-analysis of early and late outcomes of the Ross/Ross-Konno procedures in neonates/infants. Methods A meta-analysis was performed in accordance with PRISMA guidelines. We used Ovid versions of MEDLINE/PubMed for relevant studies and included those that reported Ross/Ross-Konno operations in neonates/infants and at least one of the predetermined clinical outcomes. I2 and double arcsine methods assessed the heterogeneity between pooled estimates. We used a random-effect model to account for heterogeneity with MetaXL. We calculated point estimates of a pooled estimates along with its 95% CI. Results 587 neonate/infant patients were included with median age of 87.5 days old. The follow-up range was five days to 23 years. Early mortality reported in 25 studies with pooled estimates of 18.3% (95% CI: 13.6%-23.5%). Estimates ranged from 0% to 50% with relatively substantial heterogeneity ( P = .01, I2 = 48.6%). Late mortality reported in 22 studies with pooled incidence of 9.7% (95% CI: 5.9%-14.3%). Estimates ranged from 0% to 53% with relatively substantial heterogeneity ( P = .01, I2 = 46.1%). Autograft reintervention reported in 18 studies with pooled estimate of 19.2% (95% CI: 7.3%-34.5%). Estimates ranged from 0% to 81.8% with high heterogeneity ( P < .001, I2 = 90.5%). Right ventricle-to-pulmonary artery conduit reintervention reported in 16 studies with pooled estimates of 32.0% (95% CI: 20.9%-44.12%). Estimates ranged from 0% to 92.3% with high heterogeneity ( P < .001, I2 = 75.9%). Conclusions The data suggest that the Ross/Ross-Konno procedure in neonates/infants still carries significant risk of early/late mortality and autograft/conduit reintervention. The high variability of results among centers confirms the need for surgical expertise and good patient selection. Prospective multicenter studies are warranted to investigate the rate of autograft reintervention and the impact on long-term survival in this specific population.
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Affiliation(s)
- Scarlett Tohme
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Shangqing Jiang
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Kanwal Farooqi
- Division of Pediatric Cardiology, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Matthew A Crystal
- Division of Pediatric Cardiology, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - David Blitzer
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Giovanni Ferrari
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Emile Bacha
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - David Kalfa
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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Vollroth M, Misfeld M, Meier S, Krögh G, Schumacher K, Wagner R, Dähnert I, Borger MA, Kostelka M. Die Ross-Operation bei Kindern: Aspekte der chirurgischen Technik. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-022-00495-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stephens EH, Chai P. Aortic Valve Surgery in the Pediatric Population. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The Ross operation provides several advantages compared to other valve substitutes to manage aortic valve disease, such as growth potential, excellent hemodynamics, freedom from oral anticoagulation and hemolysis, and better durability. However, progressive dilatation of the pulmonary autografts after Ross operation reflects the inadequate remodeling of the native pulmonary root in the systemic circulation, which results in impaired adaptability to systemic pressure and risk of reoperation after the first decade. A recently published article showed that remodeling increased wall thickness and decreased stiffness in the failed specimens after Ross operation, and the increased compliance might play a key role in determining the progressive long-term autograft root dilatation. Late dilatation can be counteracted by an external barrier which prevents failure. Therefore, an inclusion cylinder technique with a native aorta or a synthetic external support, such as Dacron, might stabilize the autograft root and improve long-term outcomes. In this article, we offer a prospective about the importance of biomechanical features in future developments of the Ross operation. Pre-clinical and clinical evaluations of the biomechanical properties of these reinforced pulmonary autografts might shed new light on the current debate about the long-term fate of the pulmonary autograft after Ross procedure.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Raja SG, Pozzi M. Growth of Pulmonary Autograft after Ross Operation in Pediatric Patients. Asian Cardiovasc Thorac Ann 2016; 12:285-90. [PMID: 15585694 DOI: 10.1177/021849230401200402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Ross procedure is being used increasingly to treat aortic valve disease in pediatric patients; however, there is an ongoing dispute about the durability of the autograft. From November 1996 to September 2003, 32 pediatric patients (mean age, 11 ± 4.5 years) underwent the Ross procedure for various aortic valve diseases, using the root replacement technique. Clinical and echocardiographic follow-up was performed early (within 30 days), at 3 to 6 months, and yearly after surgery. There were no perioperative deaths. The patients were followed-up for up to 7 years with a median interval of 36 months. Actuarial survival at 7 years was 96% ± 3% and there was 100% freedom from re-operation for autograft valve dysfunction or any other cause. The autograft annulus and sinus increased significantly in size during follow-up and the increase in size paralleled the increase in body surface area, with no evidence of disproportional dilatation. The hemodynamics at the latest follow-up were also similar to those at the time of discharge after surgery. Pulmonary autograft replacement of the aortic valve appears to be the ideal solution in pediatric patients, because of relatively low operative risk, excellent late valve function, and real potential for growth.
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Affiliation(s)
- Shahzad G Raja
- Department of Pediatric Cardiothoracic Surgery, Alder Hey Hospital, Liverpool L12 2AP, UK.
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Nappi F, Spadaccio C, Fouret P, Hammoudi N, Chachques JC, Chello M, Acar C. An experimental model of the Ross operation: Development of resorbable reinforcements for pulmonary autografts. J Thorac Cardiovasc Surg 2015; 149:1134-42. [PMID: 25659190 DOI: 10.1016/j.jtcvs.2014.12.056] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 12/06/2014] [Accepted: 12/28/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To circumvent the issue of pulmonary autograft (PA) dilation after the Ross procedure, surgical reinforcement strategies have been suggested in clinical or anecdotal series. However, no preclinical large-animal model of the Ross procedure is available, which is needed to enable full comprehension of the pathologic mechanisms and the effectiveness of reinforcement techniques during growth. Our aim was to develop a large-animal model of the Ross operation, to reproduce the clinical scenario in which this procedure might be applied, and allow for development and testing of various devices and techniques to improve PA performance. In addition, we aimed to test the effectiveness of a bioresorbable mesh for PA reinforcement. METHODS An experimental model of transposition of the pulmonary trunk as an autograft in the aortic position has been developed and performed under cardiopulmonary bypass in 20 growing lambs, aged 3 months. The experimental design included: a control group that underwent PA transposition; a group in which the PA was reinforced with an external, synthetic, nonresorbable, polypropylene grid; and a group that received various combinations of resorbable meshes. Animals were followed up during growth for 6 months by angiography and echocardiography and eventually killed for pathologic analysis. RESULTS All animals survived the procedure with no complications. The model was easy and reproducible. Resorbable meshes prevented PA dilation and preserved its progressive growth process, aiding histologic remodelling. CONCLUSIONS We developed an easy and reproducible model of the Ross procedure, allowing for a reliable simulation of the clinical scenario. Resorbable PA reinforcement may represent an interesting option in this context.
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Affiliation(s)
- Francesco Nappi
- Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, Paris, France.
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Pierre Fouret
- Department of Pathology, Hôpital de la Salpétrière, Paris, France
| | - Nadjib Hammoudi
- Department of Cardiology, Hôpital de la Salpétrière, Paris, France
| | - Juan Carlos Chachques
- Laboratory of Biosurgical Research, Carpentier Foundation, Pompidou Hospital, University Paris Descartes, Paris, France
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hôpital de la Salpétrière, Paris, France
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Botha CA. The Ross operation: utilization of the patient’s own pulmonary valve as a replacement device for the diseased aortic valve. Expert Rev Cardiovasc Ther 2014; 3:1017-26. [PMID: 16292993 DOI: 10.1586/14779072.3.6.1017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Prosthetic heart valves have been outpaced by progress in cardiac surgery. Early biologic valve prostheses consisted of tissues mounted on a rigid stent, and did not require anticoagulation, but rarely survived two decades. Subsequently, durable mechanical valve prostheses dominated despite, the requisite anticoagulation. The mechanical design remains imperfect, with obstruction to flow, turbulence, hematological changes and also, occasionally audible clicks. Reports documenting superior function for cryopreserved human aortic heart valves (homografts) without these problems, albeit with limited durability, followed. The marketing of 'stentless biologic valves', mimicking these attributes was a reaction to the shortage of homografts. These imperfections explain the rediscovery of the Ross operation, in which the patient's pulmonary valve (autograft) is excised to replace the aortic valve. The autograft is living tissue, complete with attributes of a healthy heart valve, including growth and durability. The pulmonary valve, where lower pressure and oxygen saturation retards degeneration, is substituted with a pulmonary homograft. The Ross operation is exacting and leaves the patient with two potentially malfunctioning valves.
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Affiliation(s)
- Cornelius A Botha
- Cardiac Clinic Bodensee (Lake Constance), Weinbergstrasse 1, Kreuzlingen, CH 8280, Switzerland.
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9
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Brancaccio G, Polito A, Hoxha S, Gandolfo F, Giannico S, Amodeo A, Carotti A. The Ross procedure in patients aged less than 18 years: The midterm results. J Thorac Cardiovasc Surg 2014; 147:383-8. [DOI: 10.1016/j.jtcvs.2013.02.037] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 11/18/2012] [Accepted: 02/13/2013] [Indexed: 10/27/2022]
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Hörer J, Kasnar-Samprec J, Charitos E, Stierle U, Bogers AJJC, Hemmer W, Hetzer R, Hübler M, Robinson DR, Sievers HH, Lange R. Patient Age at the Ross Operation in Children Influences Aortic Root Dimensions and Aortic Regurgitation. World J Pediatr Congenit Heart Surg 2013; 4:245-52. [DOI: 10.1177/2150135113485763] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The Ross operation provides the advantage of growth potential of the pulmonary autograft in the aortic position. However, development of autograft dilatation and regurgitation may occur. We sought to assess the progression of autograft diameters and aortic regurgitation (AR) with regard to patient age at the time of the Ross operation. Methods: Autograft echo dimensions from 48 children <16 years of age at the time of the Ross operation, who had follow-up echocardiograms at <20 years of age, were analyzed using hierarchical multilevel modeling. The z values of autograft dimensions were calculated according to the normal aortic dimensions. Mean follow-up was 5.1 ± 3.3 years. The mean age at the time of the Ross operation was 10.0 ± 4.3 years. Results: The mean z values of all patients showed a significant increase with follow-up time at the sinus (0.5 ± 0.1/year, P < .001) and the sinotubular junction (0.7 ± 0.2/year, P < .001) but not at the annulus (0.1 ± 0.1/year, P = .59). There was no significant difference in the z values of sinus and the sinotubular junction between younger and older children at implantation and with time. The initial annulus z value was significantly larger in younger children ( P < .0001), whereas the annual increase was significantly higher in older children ( P = .021). Age at operation has no impact on the initial AR grade ( P = .60). The AR tends to increase more quickly in older patients ( P = .040). Sinus and sinotubular junction dilate with time, regardless of patient age. Conclusions: Young children show larger initial annulus sizes than older children. However, annulus diameters tend to normalize in young children, whereas they increase in older children. Autograft regurgitation develops slowly, but significantly, and predominantly in older children. Stabilizing measures to prevent autograft root dilatation are warranted in adolescents, but they are not required in young children.
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Affiliation(s)
- Jürgen Hörer
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technische Universität München, Munich, Germany
| | - Jelena Kasnar-Samprec
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technische Universität München, Munich, Germany
| | - Efstratios Charitos
- Department of Cardiac Surgery, University Clinic Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Ulrich Stierle
- Department of Cardiac Surgery, University Clinic Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Ad J. J. C. Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | | | - Derek R. Robinson
- Department of Mathematics, School of Science and Technology, University of Sussex, Brighton, United Kingdom
| | - Hans H. Sievers
- Department of Cardiac Surgery, University Clinic Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technische Universität München, Munich, Germany
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Pees C, Laufer G, Michel-Behnke I. Similarities and differences of the aortic root after arterial switch and ross operation in children. Am J Cardiol 2013; 111:125-30. [PMID: 23062315 DOI: 10.1016/j.amjcard.2012.08.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 08/22/2012] [Accepted: 08/22/2012] [Indexed: 11/26/2022]
Abstract
Pulmonary root dilation and valve regurgitation if translocated into the aortic position is frequently seen in children with transposition of the great arteries (TGA) after an arterial switch operation, as well as in patients after the Ross procedure. Many mechanisms are thought to be responsible for the progressive dilation. Despite the differences between the 2 groups, the similarity of having the pulmonary valve and its adjacent tissue working in the systemic circulation might have a comparable effect on the neoaortic root dimensions and elasticity. We prospectively recruited 52 patients with TGA, 23 Ross patients, and 48 healthy subjects for echocardiographic assessment of their aortic valve, root, sinutubular junction, and ascending aortic dimensions and elasticity. The data were compared, stratified by patient age at investigation and the duration of follow-up postoperatively. In relation to the healthy subjects, the neoaortic root dimensions were significantly larger and the tissue stiffer and less distensible in those with TGA and those who had undergone the Ross procedure. Although the pulmonary valve of the Ross patients had been under systemic pressure load for a significantly shorter period (4.4 ± 3.6 vs 10.1 ± 5.5 years), the dimensions and elasticity values had deteriorated more. These differences could neither be clearly attributed to the age differences at surgery or to an auxiliary congenital ventricular septal defect in those with TGA or the aortic valve phenotype before the Ross operation. In conclusion, the worse outcome of the neoaortic root dimensions and elasticity in the Ross patients should at least be partly related to the different predefined pulmonary artery structures and the different development of the normal and transposed pulmonary arteries.
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Mitropoulos FA, Kanakis MA, Apostolopoulou SC, Rammos S, Anagnostopoulos CE. The Ross-Konno procedure as reoperative treatment in a young adult with congenital aortic stenosis. Heart Surg Forum 2012; 15:E182-4. [PMID: 22917820 DOI: 10.1532/hsf98.20111091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Mechanical and biological prostheses are valid options when aortic valve replacement is necessary. The Ross procedure is also an alternative solution, especially for young patients. We describe the case of a young patient with congenital aortic stenosis and bicuspid aortic valve who presented with dyspnea on exertion. An open commissurotomy was performed, and within 8 months the patient developed recurrent symptoms of severe aortic stenosis. He underwent redo sternotomy and a Ross-Konno procedure with an uneventful recovery.
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Affiliation(s)
- Fotios A Mitropoulos
- Department of Pediatric Cardiac Surgery and Congenital Heart Surgery, Onassis Cardiac Center, Athens, Greece.
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Abstract
The proximity of the coronary arteries and the bundle of His to the aortic valve may contribute to the pathogenesis of arrhythmias in patients with aortic valve disease. Severe aortic valve disease may also adversely alter left ventricular hemodynamics (end-diastolic dimensions and wall stress) and thus create a substrate for ventricular arrhythmias before any intervention is performed. The severity of these arrhythmias depends on the severity of the underlying substrate (or the specific problem, such as aortic stenosis or aortic regurgitation), the age at which the aortic valve intervention was performed, the type of intervention (i.e. transcatheter aortic valve interventions or open aortic valve replacement or repair), and the reversibility of the altered hemodynamics after surgery. Both bradyarrhythmias and tachyarrhythmias are known complications of aortic valve interventions. Although data are scant, this review summarizes the incidence of arrhythmias before and after aortic valve interventions from a pediatric perspective.
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Ryan WH, Prince SL, Culica D, Herbert MA. The Ross Procedure Performed for Aortic Insufficiency Is Associated With Increased Autograft Reoperation. Ann Thorac Surg 2011; 91:64-9; discussion 69-70. [DOI: 10.1016/j.athoracsur.2010.10.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 10/01/2010] [Accepted: 10/05/2010] [Indexed: 11/30/2022]
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Sievers HH, Stierle U, Charitos EI, Hanke T, Misfeld M, Matthias Bechtel JF, Gorski A, Franke UFW, Graf B, Robinson DR, Bogers AJJC, Dodge-Khatami A, Boehm JO, Rein JG, Botha CA, Lange R, Hoerer J, Moritz A, Wahlers T, Breuer M, Ferrari-Kuehne K, Hetzer R, Huebler M, Ziemer G, Takkenberg JJM, Hemmer W. Major adverse cardiac and cerebrovascular events after the Ross procedure: a report from the German-Dutch Ross Registry. Circulation 2010; 122:S216-23. [PMID: 20837916 DOI: 10.1161/circulationaha.109.925800] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. METHODS AND RESULTS One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. CONCLUSIONS Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.
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Affiliation(s)
- Hans-H Sievers
- University of Luebeck, Department of Cardiac and Thoracic Vascular Surgery, Luebeck, Germany
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Hörer J, Stierle U, Hanke T, Takkenberg J, Bogers A, Hemmer W, Rein J, Hübler M, Hetzer R, Sievers H, Lange R. Die Ross-Operation bei Kindern. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-010-0768-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Hörer J, Hanke T, Stierle U, Takkenberg JJM, Bogers AJJC, Hemmer W, Rein JG, Hetzer R, Hübler M, Robinson DR, Sievers HH, Lange R. Neoaortic root diameters and aortic regurgitation in children after the Ross operation. Ann Thorac Surg 2009; 88:594-600; discussion 600. [PMID: 19632419 DOI: 10.1016/j.athoracsur.2009.04.077] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 04/20/2009] [Accepted: 04/22/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND For children who require aortic valve replacement, the Ross operation provides a unique advantage of growth potential of the pulmonary autograft in the aortic position. This study assessed the progression of autograft root diameters and its effect on aortic regurgitation (AR). METHODS Neoaortic echo dimensions from 48 children (<16 years) undergoing Ross operation who had follow-up echocardiograms before age 20 were analyzed (mean follow-up, 5.1 +/- 3.3 years). RESULTS The mean age at the time of the Ross operation was 10.0 +/- 4.3 years. Mean z values of the neoaortic annulus (1.5 +/- 0.4), sinus (2.5 +/- 0.4), and sinotubular junction (2.6 +/- 0.9) when the autograft was implanted were significantly larger compared with normal values (p < 0.001, all). The mean z values significantly increased with follow-up at the level of the sinus (0.5 +/- 0.1/year, p < 0.001) and the sinotubular junction (0.7 +/- 0.2, p < 0.001), but not at the level of the annulus (0.1 +/- 0.1, p = 0.59). AR increased with follow-up time (0.07 +/- 0.02 grade/year, p < 0.001). AR increased with sinotubular junction diameter (p = 0.028), but there was not significant evidence of an association with annulus diameter (p = 0.25) or sinus diameter (p = 0.40). CONCLUSIONS Children undergoing Ross operation have larger neoaortic root dimensions than healthy children. Growth of the annulus matches somatic growth. The diameters of the sinus and the sinotubular junction increase significantly relative to somatic growth. The latter may explain the development of AR.
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Affiliation(s)
- Jürgen Hörer
- Department of Cardiovascular Surgery, German Heart Center Munich at Technical University, Munich, Germany.
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Goldberg SP, McCanta AC, Campbell DN, Carpenter EV, Clarke DR, da Cruz E, Ivy DD, Lacour-Gayet FG. Implications of incising the ventricular septum in double outlet right ventricle and in the Ross-Konno operation. Eur J Cardiothorac Surg 2009; 35:589-93; discussion 593. [PMID: 19269838 DOI: 10.1016/j.ejcts.2008.12.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 12/17/2008] [Accepted: 12/19/2008] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Incision into the ventricular septum in complex biventricular repair is controversial, and has been blamed for impairing left ventricular function. This retrospective study evaluates the risk of a ventricular septal incision in patients undergoing double outlet right ventricle (DORV) repair and Ross-Konno procedure. METHODS From January 2003 to September 2007, 11 patients with DORV had a ventricular septum (VS) incision and 12 DORV patients did not. Sixteen patients had a Ross-Konno, and 16 had an isolated Ross procedure. The ventricular septal incision was made to match at least the diameter of a normal aortic annulus. In DORV, the VSD was enlarged superiorly and to the left. In the Ross-Konno, the aortic annulus was enlarged towards the septum posteriorly and to the left. RESULTS The median follow-up for the study is 19 months (1 month-4 years). For DORV, there were no significant differences in discharge mortality (p=0.22), late mortality (p=0.48), or late mortality plus heart transplant (p=0.093). Although patients with DORV and VSD enlargement have a more complex postoperative course, there were no differences in ECMO use (p=0.093), occurrence of permanent AV block (p=0.55), left ventricular ejection fraction (LVEF) (p=0.40), or shortening fraction (LVSF) (p=0.50). Similarly, for the Ross-Konno there were no significant differences in discharge mortality (p=0.30), late mortality (p=NS), LVEF (p=0.90) and LVSF (p=0.52) compared to the Ross, even though the Ross-Konno patients were significantly younger (p<0.0001). CONCLUSION Making a ventricular septal incision in DORV repair and in the Ross-Konno operation does not increase mortality and does not impair the LV function. The restriction of the VSD remains an important issue in the management of complex DORV. These encouraging results need to be confirmed by larger series.
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El-Hamamsy I, Yacoub MH. Repair, replacement, Ross: how I approach the older child with mixed aortic stenosis/aortic insufficiency. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009; 12:133-138. [PMID: 19349028 DOI: 10.1053/j.pcsu.2009.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Most children with aortic valve disease present with isolated aortic regurgitation or stenosis, in which case valve repair is often possible, thus delaying or eliminating the need for valve replacement. In the child with mixed aortic stenosis and regurgitation, repair is often more complex and less successful, requiring replacement of the valve and/or root. Several elements require careful consideration in children including growth potential of the child, risk of future reoperations, and the need for anticoagulation. A formal decision tree in this context is difficult because of the high variability between patients and pathologies and the lack of prospective randomized data. Nevertheless, we here present our approach to the child with mixed aortic stenosis and regurgitation, exploring the various options and explaining our favored approach.
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Affiliation(s)
- Ismail El-Hamamsy
- Harefield Heart Science Center, National Heart and Lung Institute, Imperial College London, UK
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Nagy Z, Watterson KG. [Ross procedure versus mechanical aortic valve replacement in young adults]. Magy Seb 2008; 61 Suppl:23-7. [PMID: 18504233 DOI: 10.1556/maseb.61.2008.suppl.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED Clinical and echocardiographic data of young adults undergoing aortic valve replacement either by pulmonary autograft or mechanical prosthesis were analysed. Between 1995 and 2002 thirty-four consecutive patients (age 26.2 +/- 5.3 years) underwent aortic valve surgery by the authors (17 Ross procedures and 17 mechanical prostheses). Reasons for not doing a Ross procedure were size mismatch (3); anomalous coronaries (2); thin pulmonary sinuses (2); severe hypertension (2); poor LV function (2); active endocarditis (1); lack of suitable homograft (2) and the patient's request (3). There was no early mortality detected, although all patients were followed up (64.4 +/- 26.8 months). Two late deaths occurred in the prosthetic valve group (1 sepsis secondary to endocarditis, 1 end-stage heart failure). During the follow-up time there were two cases of endocarditis and two anticoagulant-related complications in the mechanical valve group. In the Ross group, one patient required reoperation for early endocarditis secondary to an infected homograft. The only late complication after the Ross procedure was a minor pulmonary embolism. Echocardiography showed a competent autograft in all but one patient. LV end diastolic dimensions and wall thickness were significantly smaller in the autograft patients (p = 0.049 andp = 0.017, respectively). CONCLUSIONS Freedom from anticoagulation-related complications and unrestricted lifestyle as well as the more complete LV mass regression make the autograft a superior valve substitute in young adults; however it is not suitable for everyone.
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Affiliation(s)
- Zsolt Nagy
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Kardiológiai Intézet, Szívsebészeti Központ, Debrecen.
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Morales DL, Carberry KE, Balentine C, Heinle JS, McKenzie ED, Fraser Jr CD. Selective Application of the Pediatric Ross Procedure Minimizes Autograft Failure. CONGENIT HEART DIS 2008; 3:404-10. [DOI: 10.1111/j.1747-0803.2008.00221.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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A single center's experience with the Ross procedure in pediatrics. Pediatr Cardiol 2008; 29:894-900. [PMID: 18401635 DOI: 10.1007/s00246-008-9224-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 01/18/2008] [Accepted: 03/22/2008] [Indexed: 10/22/2022]
Abstract
The use of a pulmonary autograft for aortic valve replacement (AVR) has become more prevalent than other forms of AVR in the pediatric population. We reviewed the data on pediatric patients who underwent the Ross procedure at our institution from 1993 to 2005. Sixty patients <18 years old who underwent a Ross procedure had available clinical and echocardiographic data collected and statistical analysis performed. Mortality rate was 3.3%, while overall survival and freedom from reoperation of either the homograft or the autograft were 96.7% and 66.2%, respectively, at 10 years. Freedom from reoperation of the left ventricular outflow tract was 60.5% at 10 years. Echocardiographic data showed aortic regurgitation to be mild or less in 76% of patients by last follow-up, while dilation of the sinuses of Valsalva had occurred in 52%. Compared to other AVR options, the Ross procedure in eligible pediatric patients demonstrates good intermediate survival rates and continued growth potential, yet a time-dependent need for reoperation.
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Marino BS, Pasquali SK, Wernovsky G, Pudusseri A, Rychik J, Montenegro L, Shera D, Spray TL, Cohen MS. Accuracy of intraoperative transesophageal echocardiography in the prediction of future neo-aortic valve function after the Ross procedure in children and young adults. CONGENIT HEART DIS 2008; 3:39-46. [PMID: 18373748 DOI: 10.1111/j.1747-0803.2007.00156.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Neo-aortic insufficiency (neo-AI) has been noted following the Ross procedure. The purpose of this study was to evaluate the ability of intraoperative transesophageal echocardiography (TEE) to predict future neo-AI in pediatric patients undergoing the Ross from January 1995 to December 2003, who had an intraoperative TEE, and discharge and follow-up transthoracic (TTE) echocardiograms. DESIGN Retrospective case series. PATIENTS All patients who underwent the Ross procedure at Children's Hospital of Philadephia between January 1995 and December 2003, and had an intraoperative TEE, discharge, and follow-up (>6 months) transthoracic echocardiogram (TTE) (by July 1, 2004) were included. OUTCOME MEASURES Grade of neo-AI was assessed on intraoperative TEE, discharge, and follow-up TTE echocardiogram reports. RESULTS Follow-up was available in 99/115 (86%) survivors. Median age at Ross was 9.3 years (4 days-34 years). No patient had more than mild neo-AI on intraoperative TEE. At discharge, 2 patients (2%) had moderate neo-AI. At most recent follow-up (median 4.2 years, 8 months-9.3 years), 21 patients (21%) had moderate or greater neo-AI; 9 underwent neo-aortic reintervention. The presence of any neo-AI on intraoperative TEE had 100% sensitivity and negative predictive value for diagnosing moderate or greater neo-AI at discharge. Patients who had mild neo-AI on TEE were more likely to have moderate or greater neo-AI at most recent follow-up than those patients with no neo-AI on TEE (9% vs. 30%, P = 0.01). CONCLUSION Intraoperative TEE is an excellent screening tool for the presence of significant neo-AI at the time of hospital discharge. Neo-AI progresses over time after Ross procedure and is more likely to progress in those patients with neo-AI on intraoperative TEE. However, predictive validity decreases over time as neo-AI progresses.
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Affiliation(s)
- Bradley S Marino
- Children's Hospital of Philadelphia, Pediatrics Divisions of Cardiology, Philadelphia, PA, USA.
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Stewart RD, Backer CL, Hillman ND, Lundt C, Mavroudis C. The Ross Operation in Children: Effects of Aortic Annuloplasty. Ann Thorac Surg 2007; 84:1326-30. [PMID: 17888991 DOI: 10.1016/j.athoracsur.2007.03.097] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 03/09/2007] [Accepted: 03/13/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Autograft dilatation and progressive neoaortic regurgitation after the Ross procedure prompted us to perform routine aortic annuloplasty. The purpose of this review is to evaluate the success of this technical modification in preventing autograft failure requiring reoperation. METHODS From 1994 to 2005, 46 children and young adults with a mean age of 12.9 +/- 4.9 years (range, 14 months to 21 years) underwent a Ross procedure; 19 of 46 patients had prior aortic valve surgery. Neoaortic valve function and need for reintervention were compared between patients who had a Ross procedure without annuloplasty (n = 20) and those who had an annular reduction prior to the autograft anastomosis (n = 26). RESULTS There were no early or late deaths during a mean follow-up of 65 +/- 36 months. Mean hospital stay was 6.6 +/- 2.9 days. Two patients required early intervention (eight days) for significant neoaortic regurgitation; one patient required repair of a left ventricular outflow tract pseudoaneurysm a month after emergent Ross procedure for endocarditis, and one patient required replacement of a stenotic homograft at five years. Five patients (13%) required autograft repair (n = 3) or replacement (n = 2) for progressive neoaortic regurgitation, two of the 26 patients had reduction annuloplasty (8%), and three of the 20 patients did not (15%) (p = 0.6). There was a similar incidence of neo-sinus of Valsalva dilatation 37 mm or greater in patients with (53%) and without (36%) annuloplasty (p = 0.5). CONCLUSIONS The Ross procedure remains an excellent option for valve replacement in children and young adults given the alternatives and can be performed with very low mortality. However, in this series of Ross operations in children, routine use of aortic annuloplasty failed to prevent neoaortic regurgitation requiring reoperation.
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Affiliation(s)
- Robert D Stewart
- Division of Cardiovascular and Thoracic Surgery, Children's Memorial Hospital, Chicago, Illinois 60614, USA
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McMullan DM, Oppido G, Davies B, Kawahira Y, Cochrane AD, d'Udekem d'Acoz Y, Penny DJ, Brizard CP. Surgical strategy for the bicuspid aortic valve: tricuspidization with cusp extension versus pulmonary autograft. J Thorac Cardiovasc Surg 2007; 134:90-8. [PMID: 17599491 DOI: 10.1016/j.jtcvs.2007.01.054] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 01/02/2007] [Accepted: 01/08/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The congenitally bicuspid aortic valve is the most common etiologic factor associated with clinically significant aortic stenosis and/or regurgitation in pediatric patients. Beyond infancy, surgical intervention typically involves valve repair with cusp thinning and commissurotomy or valve replacement, primarily with pulmonary autograft in the current era. An aortic valve repair technique using tricuspidization with cusp extension was introduced in 1999. This study compares the midterm clinical outcome in patients undergoing valve repair by tricuspidization with cusp extension with those receiving a pulmonary autograft (Ross). METHODS A retrospective study was performed on all consecutive patients with symptomatic bicuspid aortic valve disease who underwent tricuspidization with cusp extension or a Ross procedure between 1999 and 2005. In both groups, all patients were at least 1 year of age at time of the operation. RESULTS During this period, 21 children (median age 12.6 years, range 2.6-18 years) underwent tricuspidization with cusp extension (TCE group) and 25 children (median age 10.2 years, range 11.5 months-20.1 years) underwent the Ross procedure. Prior balloon valvuloplasty was performed in 5 (24%) of the children in the TCE group and 16 (64%) of the children in the Ross group. Prior surgical commissurotomy was performed in 4 (19%) TCE patients and in 9 (36%) Ross patients. During a median follow-up period of 36.4 months (range 2.5 months-7.4 years), 2 (10%) patients in the TCE group required valve-preserving early revision of the repair, 2 (10%) TCE patients required subsequent aortic valve replacement at 16 and 33 months, 1 (4%) Ross patient required subsequent valve repair at 5 years, and 1 (4%) Ross patient underwent cardiac transplantation at 46 months. At 36 months, the actuarial freedom from reintervention on the aortic valve or autograft was 90% in the TCE group, with 11 patients at risk, and 100% in Ross patients, with 13 patients at risk (P = .39); the freedom from moderate valve dysfunction or reintervention was 66% for TCE patients and 95% for Ross patients (P = .07). There were no deaths, and all but 1 Ross patient remain in New York Heart Association class I. CONCLUSIONS Reintervention rates in patients undergoing tricuspidization with cusp extension or a primary Ross procedure are similar. Valve performance in the TCE group is satisfactory at midterm follow-up, but the Ross repair appears to provide greater stability of valve function. These results suggest that repair with valve tricuspidization and cusp extension provides reliable palliation of the symptomatic bicuspid aortic valve.
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Chiappini B, Absil B, Rubay J, Noirhomme P, Funken JC, Verhelst R, Poncelet A, El Khoury G. The Ross Procedure: Clinical and Echocardiographic Follow-Up in 219 Consecutive Patients. Ann Thorac Surg 2007; 83:1285-9. [PMID: 17383328 DOI: 10.1016/j.athoracsur.2006.11.072] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 11/21/2006] [Accepted: 11/21/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The replacement of the diseased aortic valve with a pulmonary autograft has been shown to provide excellent hemodynamic results and to be associated with low morbidity and mortality rates. METHODS From 1991 to 2005, 219 patients undergoing the Ross operation were identified. All patients underwent transthoracic echocardiography at discharge and were scheduled for a yearly study thereafter. The echocardiographic study consisted of a morphologic analysis of the pulmonary autograft with measurement of end-systolic diameters at three levels: annulus, sinuses of Valsalva, and origin of the ascending aorta 2 cm above the sinotubular junction. The dynamic analysis evaluated the function of the aortic autograft and the pulmonary homograft. Maximal and mean aortic and pulmonary transvalvular pressure gradients were investigated. RESULTS The 30-day mortality was 1.8% (n = 4). Cardiac deaths were not related to the autograft. The 10-year actuarial survival was 95.7% +/- 2.1%. Six patients (2.8%) had grade 2 autograft valve regurgitation. No grade 3 or 4 pulmonary regurgitation was identified. At their most recent follow-up, 28 patients (13.1%) had grade 1 insufficiency of the pulmonary homograft, and 10 patients (4.6%) had a peak transvalvular gradient of 17.9 +/- 10.2 mm Hg. CONCLUSIONS Our current experience suggests that replacement of the aortic root with a pulmonary autograft can be safely performed in infants, children, and adults and is associated with low mortality and morbidity rates. It constitutes an elegant alternative to the use of prosthetic valves in the treatment of aortic valve diseases.
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Affiliation(s)
- Bruno Chiappini
- Department of Thoracic and Cardiovascular Surgery, Saint Luc Hospital, Université Catholique de Louvain, Brussels, Belgium.
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Berdajs D, Zünd G, Schurr U, Camenisch C, Turina MI, Genoni M. Geometric models of the aortic and pulmonary roots: suggestions for the Ross procedure. Eur J Cardiothorac Surg 2006; 31:31-5. [PMID: 17126557 DOI: 10.1016/j.ejcts.2006.10.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2006] [Revised: 10/27/2006] [Accepted: 10/31/2006] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To discuss geometric factors, which may influence long-term results relating to homograft competence following the Ross procedure, we describe the 3D morphology of the pulmonary and aortic roots. MATERIALS Measurements were made on 25 human aortic and pulmonary roots. Inter-commissural distances and the heights of the sinuses were measured. For geometrical reconstruction the three commissures and their vertical projections at the root base were used as reference points. RESULTS In the pulmonary root, the three inter-commissural distances were of similar dimensions (17.9+/-1.6mm, 17.5+/-1.4mm and 18.6+/-1.5mm). In the aortic root, the right inter-commissural distance was greatest (18.8+/-1.9mm), followed by the non-coronary (17.4+/-2.0mm) and left coronary sinus commissures (15.2+/-1.9mm). The mean height of the left pulmonary sinus was greatest (20+/-1.7mm) followed by the anterior (17.5+/-1.4mm) and right pulmonary sinus (18+/-1.66mm). In the aortic root, the height of the right coronary sinus was the greatest (19.4+/-1.9mm) followed by the heights of the non-coronary (17.7+/-1.8mm) and left coronary sinus (17.4+/-1.4mm). Measured differences between parameters determine the tilt angle and direction of the root vector. The tilt angle in the pulmonary root averaged 16.26 degrees , respectively; for the aortic roots, it was 5.47 degrees . CONCLUSIONS Herein we suggest that the left pulmonary sinus is best implanted in the position of the right coronary sinus, the anterior pulmonary in the position of the non-coronary sinus and the right pulmonary sinus in the position of the left coronary sinus. In this way, the direction of the pulmonary root vector will be parallel to that of the aortic root vector.
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Affiliation(s)
- Denis Berdajs
- Department of Cardiovascular Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland.
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Brown JW, Ruzmetov M, Vijay P, Rodefeld MD, Turrentine MW. The Ross-Konno Procedure in Children: Outcomes, Autograft and Allograft Function, and Reoperations. Ann Thorac Surg 2006; 82:1301-6. [PMID: 16996923 DOI: 10.1016/j.athoracsur.2006.05.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 04/27/2006] [Accepted: 05/03/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Ross aortic valve replacement with a modified Konno-type enlargement Ross-Konno procedure of the aortic annulus and subannular region allows an autograft aortic valve replacement for children with significant annular and subannular hypoplasia. The potential for growth and the proven durability of the autograft make the Ross-Konno procedure an ideal aortic valve replacement for this subgroup with multilevel left ventricular outflow tract obstruction. We reviewed our institutional midterm experience to assess autograft and homograft hemodynamics, and management after a Ross-Konno procedure. METHODS Between 1995 and 2005, 14 consecutive children (mean age, 6.4 +/- 5.9 years; range, 1 month to 17 years) underwent the Ross-Konno procedure. All children had severe to critical aortic stenosis or multilevel left ventricular outflow tract obstruction. RESULTS There was 1 early and 1 late death with a mean follow-up of 5.7 +/- 3.6 years. Actuarial survival at 10 years was 86%. Three patients underwent right ventricular outflow tract reoperation for conduit replacement for homograft dysfunction and one patient required redo aortic root replacement with a mechanical valves for progressive aortic insufficiency. Freedom from right ventricular outflow tract and autograft reoperation at 10 years is 77% and 92%, respectively. Aortic annular dilation was not observed in all patients. Univariate and multivariate analysis identified no risk factors for autograft or homograft valve-related reoperation. CONCLUSIONS The Ross-Konno procedure is an excellent technique to treat complex multilevel left ventricular outflow tract obstruction in children with significant annular and subannular hypoplasia. The autograft demonstrated durability without development of aortic stenosis or progressive dilation and a low incidence of developing progressive aortic insufficiency. Enlargement of the aortic annulus appear to parallel somatic growth in most instances.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA.
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Quader MA, Rosenthal GL, Qureshi AM, Mee RBB, Mumtaz MA, Joshi R, Duncan BW. Aortic valve repair for congenital abnormalities of the aortic valve. Heart Lung Circ 2006; 15:248-55. [PMID: 16829195 DOI: 10.1016/j.hlc.2006.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 02/22/2006] [Accepted: 05/08/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Due to shortcomings of any valve replacement, repairing and retaining the native valve may be beneficial for congenital aortic valve disease. METHODS Retrospective review of data and follow-up of aortic valve repair from a single institution. RESULTS From 1993 to 2001, 56 patients underwent aortic valve repair [median age 13.4 years (range 1 day to 45 years)]. The predominant aortic valve lesion was mixed aortic stenosis/aortic insufficiency 25 (45%), aortic insufficiency 24 (43%) and aortic stenosis 7 (13%). Repair techniques included sub-commissural plication 36 (64%), commissurotomy 24 (43%), cusp plication 15 (27%), pericardial patch cusp extension 8 (14%) and resuspension of commissures 4 (7%). Most patients (88%) required a combination of techniques; 61% required additional procedures. Hospital survival was 55/56 [98%; (95% CI 91-100%)] no patient was discharged on anticoagulation for aortic valve pathology. Fifty-three patients [95%; (95% CI 85-98%)] remain alive after a median follow-up of 37 months; four survivors required aortic valve replacement and two required repeat aortic valve repair [84%; (95% CI 72-91%) reintervention-free survival]. CONCLUSIONS (1) In this study, aortic valve repair for congenital abnormalities avoided reoperation in the majority of patients, avoided anticoagulation and retained growth potential of the valve. (2) Repeat aortic valve repair or replacement was used to treat subsequent valve deterioration.
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Affiliation(s)
- Mohammed A Quader
- Department of Pediatric and Congenital Heart Surgery/M41, Children's Hospital, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Tiete AR, Sachweh JS, Groetzner J, Gulbins H, Muehler EG, Messmer BJ, Daebritz SH. Systemic mechanical heart valve replacement in children under 16 years of age. Clin Res Cardiol 2006; 95:281-8. [PMID: 16680580 DOI: 10.1007/s00392-006-0376-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Accepted: 02/02/2006] [Indexed: 11/28/2022]
Abstract
UNLABELLED We report the early and late outcome following left-sided mechanical heart valve replacement in children. Between 10/1981 and 02/2001, 27 children (13 male, mean age 7.2 +/- 5.2 years, range 0.53-15.7 years) underwent mechanical mitral (MVR 16), aortic (AVR 9) or double valve replacement (DVR 2) with St. Jude Medical valves. Eighteen children (66.7%) had undergone previous cardiac surgery. Valve disease was congenital in 23, due to endocarditis in 2 and rheumatic in 2 patients. Concomitant cardiac surgery was performed in 12 patients (44.4%). Operative mortality was 3.7% (1/27). Perioperative complications were complete heart block (5) and myocardial infarction (1). Mean follow-up was 6.5+/-5.9 years (range 0.4-19 years, total 169.9 patient-years). There was one valve-related late death due to mitral valve thrombosis without phenprocoumon. Actuarial survival after 1, 5 and 10 years was 93, 93 and 93%. Late complications included endocarditis (2), minor hemorrhagic event (1) and stroke (1). Overall 10-year freedom from any anticoagulation-related adverse event under phenprocoumon was 91% (1.3%/patient year). Eight patients required reoperations: re-MVR (5; outgrowth of the prostheses (3), pannus overgrowth (2)), closure of paravalvular leak after AVR (2), and re- DVR (1; endocarditis). Actuarial freedom from reoperation after 1, 5 and 10 years was 96, 88 and 76%. CONCLUSION Mechanical valve prostheses are a valuable option for left-sided heart valve replacement in pediatric patients with good results. Operative mortality and the incidence of any valve-related events as endocarditis, reoperation, thromboembolism or anticoagulation related bleeding is acceptable.
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Affiliation(s)
- A R Tiete
- Department of Cardiac Surgery, University Hospital Grosshadern, Marchioninistr. 15, 81377, Munich, Germany.
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Doss M, Wood JP, Martens S, Wimmer-Greinecker G, Moritz A. Do pulmonary autografts provide better outcomes than mechanical valves? A prospective randomized trial. Ann Thorac Surg 2005; 80:2194-8. [PMID: 16305870 DOI: 10.1016/j.athoracsur.2005.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 05/24/2005] [Accepted: 06/03/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The objective of this study was to compare the performance of pulmonary autografts with mechanical aortic valves, in the treatment of aortic valve stenosis. METHODS Forty patients with aortic valve stenoses, and below the age of 55 years, were randomly assigned to receive either pulmonary autografts (n = 20) or mechanical valve (Edwards MIRA; Edwards Lifesciences, Irvine, CA) prostheses (n = 20). Clinical outcomes, left ventricular mass regression, effective orifice area, ejection fraction, and mean gradients were evaluated at discharge, 6 months, and one year after surgery. Follow-up was complete for all patients. RESULTS Hemodynamic performance was significantly better in the Ross group (mean gradient 2.6 mm Hg vs 10.9 mm Hg, p = 0.0005). Overall, a significant decrease in left ventricular mass was found one year postoperatively. However, there was no significant difference in the rate and extent of regression between the groups. There was one stroke in the Ross group and one major bleeding complication in the mechanical valve group. Both patients recovered fully. CONCLUSIONS In our randomized cohort of young patients with aortic valve stenoses, the Ross procedure was superior to the mechanical prostheses with regard to hemodynamic performance. However, this did not result in an accelerated left ventricular mass regression. Clinical advantages like reduced valve-related complications and lesser myocardial strain will have to be proven in the long term.
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Affiliation(s)
- Mirko Doss
- Department of Thoracic and Cardiovascular Surgery, J. W. Goethe University, Frankfurt am Main, Germany.
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Luciani GB, Favaro A, Casali G, Santini F, Mazzucco A. Ross Operation in the Young: A Ten-Year Experience. Ann Thorac Surg 2005; 80:2271-7. [PMID: 16305887 DOI: 10.1016/j.athoracsur.2005.03.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2005] [Revised: 02/20/2005] [Accepted: 03/03/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Ross operation is an alternative to mechanical aortic valve replacement in the young. However, early and late complications after operation have been reported. In order to assess the role of the Ross operation in children and young adults, a 10-year clinical experience was reviewed. METHODS Ninety male and 22 female patients, aged 29 +/- 10 years (range, 6-49) underwent cross-sectional clinic and echocardiographic examination. Indication for Ross operation was aortic regurgitation in 79 patients, stenosis in 11, and mixed lesion in 22; 82 (73%) had a bicuspid valve. Endpoints of the study were survival and freedom from autograft dilatation, from autograft and homograft dysfunction, and from reoperation. RESULTS There was 1 (1%) hospital and 1 late (1%) death, during an average follow-up of 5.1 +/- 1.9 years (range, 0.1-10.6). At 10 years, survival was 98 +/- 2%. Late autograft dilatation was identified in 32 (29%) patients and regurgitation in 15 (14%), 7 of whom had autograft dilatation. Ten-year freedom from autograft dilatation was 43 +/- 8% and from regurgitation was 75 +/- 8%. Multivariate analysis showed younger age (p = 0.05), preoperative aortic root dilatation (p = 0.02), root replacement technique (p = 0.03), and absence of pericardial strip buttressing (p = 0.04) to be predictive of autograft dilatation. Eleven (10%) patients required reoperation on the autograft (8 prosthetic valve replacement, 3 autograft root repair). Ten-year freedom from reoperation was 72 +/- 10% and from replacement of the autograft was 88 +/- 5%. Pulmonary homograft obstruction was identified in 6 (5%) patients, requiring homograft replacement in 1. All but 2 (2%) patients were in New York Heart Association class I, with a return to regular school grade or active employment. CONCLUSIONS Late outcome for the Ross procedure is excellent in terms of survival and quality of life. Late root dilatation, autograft regurgitation, and homograft stenosis, however, show increasing prevalence with time. Technical modifications of the procedure, yearly aortic root imaging, and early reintervention on the dilated neoaortic root may further enhance the durability of the autologous pulmonary valve.
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Koizumi J, Ishino K, Kawada M, Yoshizumi K, Kanki K, Sano S. Mid-term results of open aortic valvotomy for infants with critical aortic stenosis: seven-year experience including delayed Ross strategy. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2005; 53:593-7. [PMID: 16363716 DOI: 10.1007/s11748-005-0144-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVES The purpose of this study is to provide short- and mid-term results of open aortic valvotomy (OAV) for patients with critical aortic stenosis (AS). METHODS Between December 1993 and June 1996, 6 patients with critical AS underwent an OAV in our unit. Their ages and body weights at operation ranged from 1 to 65 days (median age, 9 days) and from 2.4 to 5.7 kg (median weight, 3.3 kg), respectively. Peak pressure gradient and diameter of the aortic valve ranged from 25 to 111 mmHg (mean value, 79 mmHg) and from 4.6 to 7.5 mm (mean diameter, 6.1 mm), respectively. OAV comprised the valvular commissurotomy and excision of the myxomatous nodules with cardiopulmonary bypass. RESULTS No early or late death occurred. Mean peak pressure gradient across the aortic valve was reduced to 33 mmHg (from 15 to 44 mmHg) with no aortic insufficiency in 2 patients and trivial insufficiency in 4. During the follow-up period of 6 to 9 years, 3 out of 6 patients required no reintervention. The other 3 patients required repeated valvotomy for recurrent stenosis within 0.2 to 1.3 years after the operation. Of these, 2 patients required the Ross procedure at 7 years of age or older, and another at 6 years of age awaits the Ross procedure. CONCLUSION OAV for critical AS was effective without causing mortality or significant aortic insufficiency. Our current strategy comprising the initial OAV and "delayed Ross procedure" for recurrent stenosis with or without insufficiency is a promising therapeutic option for infants with critical AS.
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Affiliation(s)
- Junichi Koizumi
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
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Acar C. Invited commentary. Ann Thorac Surg 2005; 80:494. [PMID: 16039191 DOI: 10.1016/j.athoracsur.2005.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Revised: 04/25/2005] [Accepted: 05/02/2005] [Indexed: 11/25/2022]
Affiliation(s)
- Christophe Acar
- Cardiovascular Surgery, Hôpital de la Salpétrière, 50-52 Bd Vincent Auriol, Paris, 75013, France.
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Odim J, Laks H, Allada V, Child J, Wilson S, Gjertson D. Results of Aortic Valve-Sparing and Restoration With Autologous Pericardial Leaflet Extensions in Congenital Heart Disease. Ann Thorac Surg 2005; 80:647-53; discussion 653-4. [PMID: 16039221 DOI: 10.1016/j.athoracsur.2005.03.060] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2004] [Revised: 02/23/2005] [Accepted: 03/04/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate the efficacy of aortic valve-sparing repair with glutaraldehyde-treated autologous pericardium in congenital valvular pathology. METHODS Sixty-two patients underwent reparative aortic valve surgery from January 1997 through December 2003. The mean age was 25 +/- 20 years (+/- standard deviation) (range, 10 days to 81 years). Fifty percent (31 of 62) were less than 19 years old at operation. The diagnoses included bicuspid aortic valve (39 patients), ventricular septal defect (14 patients), severe aortic stenosis (6 patients), subaortic stenosis (7 patients), bacterial endocarditis (7 patients), neonatal truncus arteriosus (2 patients), Shone's complex (2 patients), transposition complex (1 patient), double-chambered right ventricle (1 patient), and Marfan's syndrome (1 patient). Twelve patients (19 %) had prior sternotomy and cardiac operations. Valve-sparing techniques included pericardial leaflet extensions in 62 patients, creation of one or more pericardial neoaortic sinuses in 8, subcommissuroplasty in 8, pericardial patch of perforated leaflets in 9, Dacron mesh wrap (Boston Scientific, Wayne, NJ) of dilated ascending aorta in 12, and concomitant tricuspid and mitral valve repairs in 3 and 4 patients, respectively. RESULTS There was one early death (1.6%). There were no late deaths at a mean follow-up of 25 +/- 16 (range, 0.1 to 72.5 months). Six patients required reoperation and prosthetic or homograft replacement for aortic valve incompetence. One out of 6 reoperations required re-repair. The remaining patients are well with a mean aortic regurgitation grade by echocardiography of 1.3 +/- 0.9 (scale, 0 to 4). CONCLUSIONS Aortic valve repair with pericardial leaflet extension is a promising technique for the growing child.
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Affiliation(s)
- Jonah Odim
- Los Angeles Adult Congenital Heart Disease Center, Division of Cardiothoracic Surgery, Pediatric Cardiology and Ahmanson, University of California, David Geffen School of Medicine, Los Angeles, California, USA.
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Tweddell JS, Pelech AN, Jaquiss RDB, Frommelt PC, Mussatto KA, Hoffman GM, Litwin SB. Aortic valve repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:112-21. [PMID: 15818366 DOI: 10.1053/j.pcsu.2005.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Aortic valve replacement options are limited in children, and all of them have disadvantages. Aortic valve repair techniques have evolved slowly and have not gained wide acceptance; however, large series using a variety of techniques demonstrate that valve repair is possible with excellent early hemodynamics and satisfactory intermediate durability. The results of aortic valve repair at the Children's Hospital of Wisconsin are presented. Simple repairs (blunt valvotomy, commissurotomy, or commissurotomy with leaflet thinning) directed at congenital aortic stenosis resulted in 86% +/- 5% freedom from reintervention at 10 years. Repair of aortic insufficiency with ventricular septal defect (VSD) resulted in 93.3% +/- 6% freedom from reoperation at 10 years. Complex repairs included a combination of techniques and yielded 5-year freedom from reintervention of 83% +/- 7% compared with 73% +/- 11% for patients undergoing aortic valve replacement (P = .62). Aortic valve repair provides an alternative to aortic valve replacement in selected patients. The utility of aortic valve repair and aortic valve replacement must be measured not only in freedom from reintervention but also in regression of left ventricular mass and exercise testing. Improvement in outcome depends on better patient selection and suitable bioprosthetic materials.
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Affiliation(s)
- James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA
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Tiete AR, Sachweh JS, Roemer U, Kozlik-Feldmann R, Reichart B, Daebritz SH. Right ventricular outflow tract reconstruction with the Contegra bovine jugular vein conduit: a word of caution. Ann Thorac Surg 2004; 77:2151-6. [PMID: 15172286 DOI: 10.1016/j.athoracsur.2003.12.068] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Since introduction in 1999, pulmonary valve replacement in pediatric patients with the Contegra conduit (Medtronic Inc, Minneapolis, MN) has gained widespread application with increasing enthusiasm. However, unexpected graft related adverse effects may occur. METHODS Between April 2001 and December 2002, 29 patients (20 male; mean age, 3.39 +/- 3.66 years; range, 0.01 to 13.0 years; mean weight, 11.62 +/- 8.73 kg) underwent right ventricular outflow tract reconstruction with the Contegra conduit. Seventeen patients underwent primary repair, 8 had prior homografts, and 4 had other previous operations. RESULTS There were no deaths. Three early graft related complications were observed. In two infants (age, 1.8 and 3.5 months; weight, 3.6 and 3.8 kg, respectively) thrombus formation at the conduit valve was detected 2 weeks postoperatively. Under anticoagulation with low-molecular-weight heparin, thrombi resolved completely in both patients. One patient (4.5 months, 4.43 kg) developed severe regurgitation due to a fibrous layer covering the inner conduit wall and required conduit exchange 3 weeks postoperatively. After a mean follow-up time of 10.2 +/- 6.4 months all patients are in good clinical condition. However, one patient with systemic right ventricular pressure developed pseudoaneurysm at both graft insertion sites and is scheduled for reoperation. Two other patients underwent balloon dilation. Freedom from reoperation and intervention at 1 year is 89.4%. With regard to regurgitation and conduit stenosis all other conduits perform well. CONCLUSIONS Contegra conduits are an alternative to homografts for right ventricular outflow tract reconstruction. However, there is a risk of thrombus formation in small infants so that prophylactic anticoagulation may be necessary. Patients with systemic right ventricular pressure require close observation as pseudoaneurysm formation has been observed.
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Affiliation(s)
- Andreas R Tiete
- Department of Cardiac Surgery, University Hospital Grobetahadern, Munich, Germany.
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Berdat PA, Immer F, Pfammatter JP, Carrel T. Reoperations in adults with congenital heart disease: analysis of early outcome. Int J Cardiol 2004; 93:239-45. [PMID: 14975553 DOI: 10.1016/j.ijcard.2003.04.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2002] [Revised: 04/07/2003] [Accepted: 04/13/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Grown-ups with congenital heart disease (GUCH) are an increasingly important group of patients, with many requiring reoperations because of late complications or residual defects, correction after palliation, further palliation or heart transplantation. METHODS In order to identify perioperative risk factors, we have retrospectively analysed perioperative mortality and morbidity of 66 consecutive GUCH patients needing reoperations between July 1987 and December 2000 with a mean age of 28+/-12 (14.2-63.5) years and preoperative ejection fraction of 57+/-21%. Primary cardiac defects were LVOT pathology (17 patients), coarctation (10), Tetralogy of Fallot (TOF) (9), VSD (9), transposition of the great arteries (TGA) (7), Marfan syndrome (6), ASD (5) and others (3). RESULTS Reoperations included various aortic valve procedures (28), aortic replacements (16), ASD/VSD closures (16), conduits (11), RVOT procedures (8), coarctation repair (5), cardiac transplantation (3) or others (8). Early mortality was 7.6%. Serious postoperative complications occurred in 24%. Presence of cyanosis, heart failure, VSD, TGA, pulmonary atresia, correction after palliative surgery and number of previous operations were preoperative risk factors and duration of operation, cardiopulmonary bypass and aortic cross-clamp, core temperature, low output syndrome, use of epinephrine, pneumonia and ARDS, renal failure, dialysis and stroke perioperative risk factors for fatal outcome. CONCLUSIONS Reoperations in GUCH patients are mostly due to outflow tract lesions, coarctations and TOF. Perioperative risks remain important especially with cyanosis, TGA, pulmonary atresia and poor ventricular function. Therefore, close follow-up, timely referral for re-intervention and adequate perioperative management are mandatory to reduce perioperative risks and improve results.
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Affiliation(s)
- Pascal A Berdat
- University Hospital, Clinic for Cardiovascular Surgery, 3010 Bern, Switzerland.
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Mavroudis C, Sade RM. The Southern Thoracic Surgical Association 50th anniversary celebration: the impact of STSA pediatric cardiothoracic surgery manuscripts on surgical practice. Ann Thorac Surg 2003; 76:S47-67. [PMID: 14596980 DOI: 10.1016/s0003-4975(03)01508-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Members of the Southern Thoracic Surgical Association (STSA) have presented important pediatric cardiothoracic surgery papers at the annual meetings over the last 50 years. In order to determine the influence of these presentations on the practice of surgery, a review was undertaken. Early papers were characterized by emerging advances in open-heart surgery, anatomic congenital heart studies, and electrophysiologic discoveries that extended life with pacemakers. Later years were characterized by innovative myocardial preservation methods, improved cardiopulmonary bypass techniques, expanded homograft availability, emphasis on accurate repairs, intraoperative transesophageal echocardiography, and cardiopulmonary transplantation. METHODS All but one of the scientific programs of the annual meetings (that of 1964) were located. The programs were reviewed and 180 presentations were identified on topics in congenital heart disease, pediatric thoracic disease, and pediatric thoracic wall abnormalities. Of those 180 oral presentations, 155 manuscripts (86%) were eventually published or in press and available for critical review and analysis. Manuscripts were grouped by diagnosis or therapeutic intervention. We determined a "cumulative citation frequency" (CCF), which measures the number of times an article is cited in the bibliography of related papers in the universe of participating journals. The selected manuscripts were compared with the historic landmark contributions and the existing trends at the time, and the number of articles both by individual authors and from institutions were tallied. RESULTS Grouping by authors and institutions showed that 100 of 155 pediatric cardiothoracic manuscripts (65%) originated from 13 institutions. The CCF for the 20 leading articles ranged from 26 to 93. CONCLUSIONS This historical STSA 50-year record of pediatric cardiothoracic advances was accomplished in a milieu of collegial respect and camaraderie. Our annual meetings over the years have provided a venue for thoracic surgeons to share their ideas, innovations, and scientific inquiry. These contributions have significantly affected the practice of pediatric cardiothoracic surgery. The STSA has worked for 50 years and we trust that it will work for another 50 years and beyond.
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Affiliation(s)
- Constantine Mavroudis
- Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
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Svensson LG, Blackstone EH, Cosgrove DM. Surgical options in young adults with aortic valve disease. Curr Probl Cardiol 2003; 28:417-80. [PMID: 14647130 DOI: 10.1016/j.cpcardiol.2003.08.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA.
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Allen HD, Daniels CJ. The Ross operation in children and adults: introduction. PROGRESS IN PEDIATRIC CARDIOLOGY 2003. [DOI: 10.1016/s1058-9813(03)00002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Böhm JO, Botha CA, Hemmer W, Starck C, Blumenstock G, Roser D, Rein JG. Older patients fare better with the Ross operation. Ann Thorac Surg 2003; 75:796-801; discussion 802. [PMID: 12645696 DOI: 10.1016/s0003-4975(02)04495-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Ross operation has an established position in young patients. We address the question of whether any age group profits most from the Ross operation, and we compare the results in various ages. METHODS From February 1995 to August 2001 we performed 250 Ross operations. Group 1 consisted of 46 patients, ages 2 to 25 years (median age, 15 years). Group 2 consisted of 123 patients, ages 26 to 49 years (median age, 39 years). Group 3 consisted of 81 patients, ages 50 to 67 years (median age, 55 years). Echocardiography was performed perioperatively, at 2 to 6 months, and then yearly. RESULTS Mean follow-up for the three groups was 32, 31, and 28 months, respectively (p = 0.36). One patient from group 2 died after 25 months caused by suppurative pneumonia and 3 patients from group 3 died (1 from suspected acute thoracic aorta dissection at 40 months, 1 from ventricular fibrillation after 25 months, and 1 from an undiagnosed sudden death at 5 months). Autograft replacement was necessary for 3 patients from group 2 and 1 from group 3. Autograft repair was necessary for 1 patient from group 2, and pulmonary homograft reoperation was necessary for 1 patient from group 1. All other autografts currently have physiologic gradients and clinically insignificant regurgitation. Median peak gradient across the right ventricular outflow tract was 23.6 +/- 18 mm Hg for group 1, 14.6 +/- 8 mm Hg for group 2, and 11.5 +/- 7 mm Hg, which was significantly lower for group 3 patients (p < 0.001). Eleven patients are under close follow-up for right ventricular outflow tract gradients > or = 40 mm Hg; eight of these patients are from group 1, 3 are from group 2, and there are none from group 3. CONCLUSIONS Although the Ross operation provides excellent results in all age groups, the problem of right ventricular outflow tract stenosis has not been seen in patients older than 50 years, which implies that it offers superior results for aortic valve disease in middle aged and older patients.
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Affiliation(s)
- Jürgen O Böhm
- Sana Herzchirurgische Klinik Stuttgart, Stuttgart, Germany.
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Abstract
Although the Ross procedure has been performed for over three decades, its role in the management of patients with aortic valve disease is not well established. This study reviews our experience with this operation. From 1990 to 1999, 155 patients underwent the Ross procedure. The mean age of 106 men and 49 women was 35 years. Most patients (85%) had congenital aortic valve disease. The pulmonary autograft was implanted in the subcoronary position in 2 patients, as an aortic root inclusion in 78, and aortic root replacement in 75. The follow-up extended from 9 to 114 months, mean of 45 +/- 28 months, and it was complete. All patients have had Doppler echocardiographic studies. There was only one operative and one late death. The survival was 98% at 7 years. The freedom from 3+ or 4+ aortic insufficiency was 86% at 7 years and the freedom from reoperation on the pulmonary autograft was 95% at 7 years. Dilation of the aortic annulus and/or sinotubular junction was the most common cause of aortic insufficiency. One patient required three reoperations on the biological pulmonary valve. Most patients (96%) have no cardiac symptoms. The Ross procedure has provided excellent functional results in most patients, but progressive aortic insufficiency due to dilation of the aortic annulus and/or sinotubular junction is a potential problem in a number of patients.
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Affiliation(s)
- D Paparella
- Division of Cardiovascular Surgery of Toronto General Hospital and University of Toronto, Ontario, Canada
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Koul B, Lindholm CJ, Koul M, Roijer A. Ross operation for bicuspid aortic valve disease in adults: is it a valid surgical option? SCAND CARDIOVASC J 2002; 36:48-52. [PMID: 12018767 DOI: 10.1080/140174302317282384] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE The validity of the Ross operation as freestanding root replacement in adult patients with bicuspid aortic valve disease has lately been questioned. We have analyzed retrospectively our results in 23 adult patients (19 males) operated for bicuspid aortic valve disease ad modum "Ross" employing a freestanding root replacement technique. DESIGN In 9 patients the dominant aortic valve lesion was stenotic (aortic stenosis group) and in the remaining 14 patients it was aortic insufficiency (aortic insufficiency group). The fate of the pulmonary autograft in the two groups was studied. The intraoperatively measured aortic and pulmonary annuli diameters from the two groups were compared with those from a population of normal looking aortic and pulmonary valves matched for body surface area. RESULTS The aortic insufficiency group needed significant reduction of the aortic annulus diameter to conform to the size of the pulmonary autograft. The pulmonary autograft annuli in this group were significantly larger in diameter than the ones in the aortic stenosis group. The mean pulmonary annulus diameter in the aortic stenosis group was, on the other hand, significantly smaller when compared with that in the normal matched population. After a mean follow-up period of about 19 months, the aortic insufficiency group showed significant dilatation of the neo-aortic sinuses. Between the two groups, the remaining echocardiographic variables remained either stable or improved at follow-up. CONCLUSION Pre-existing larger diameters of the aortic and pulmonary annuli in the aortic insufficiency group combined with the significantly increased left ventricular end-diastolic diameters, may predispose these patients to significant dilatation of the unsupported aortic sinuses after a Ross operation. This dilatation does not, however, lead to increase in the autograft valve insufficiency at short-term follow-up if the aortic annulus and the distal ascending aorta are tailored to the size of the pulmonary autograft. Ross operation, employing freestanding aortic root replacement technique, may therefore be recommended in adult patients with bicuspid aortic valve disease with excellent short-term results.
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Affiliation(s)
- Bansi Koul
- Speciality of Cardiothoracic Surgery, Heart and Lung Division, University Hospital, Lund, Sweden.
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Pigula FA, Paolillo J, McGrath M, Gandhi SK, Myers JL, Rebovich B, Siewers RD. Aortopulmonary size discrepancy is not a contraindication to the pediatric Ross operation. Ann Thorac Surg 2001; 72:1610-3; discussion 1613-4. [PMID: 11722053 DOI: 10.1016/s0003-4975(01)03078-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Modification of the aortic annulus or the ascending aorta, or both, may be required in pediatric patients undergoing the Ross operation. The fate of these autografts remains uncertain. METHODS Retrospective review of 15 patients undergoing Ross operation without aortic annular modification (group 1), 11 patients requiring annular reduction (group 2, n = 11), and 8 patients requiring annular enlargement (group 3, n = 8). Autograft function and dimensions were evaluated by echocardiography. RESULTS Autograft insufficiency was less than or equal to mild in 33 patients and moderate in 1 patient. The annulus body surface area ratio increased in group 1 from 19.7 +/- 5 to 20.3 +/- 5 mm/M2 (p = 0.8). The average annular reduction in group 2 was 5 +/- 1.5 mm, and 10 of 11 patients required reduction of the ascending aorta (mean 11 +/- 5 mm). The annulus body surface area ratio increased from 18.6 +/- 7 to 20.5 +/- 9 mm/M2 (p = 0.2). The mean augmentation in annulus diameter in group 3 was 6 +/- 4 mm; the annulus body surface area ratio decreased from 23.7 +/- 14 to 20.3 +/- 8 mm/M2 (p = 0.5). CONCLUSIONS We continue to offer the Ross operation to pediatric patients even when aortic annular or ascending aortic size discrepancies mandate surgical modifications.
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Affiliation(s)
- F A Pigula
- Pediatric Cardiothoracic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania 15213, USA.
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da Costa FD, da Costa MB, da Costa IA, Poffo R, Sardeto EA, Matte E. Clinical experience with heart valve homografts in Brazil. Artif Organs 2001; 25:895-900. [PMID: 11903143 DOI: 10.1046/j.1525-1594.2001.06902.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this paper is to describe the development and progress of the first heart valve homograft bank in Brazil as well as to report the 5-year clinical results. The bank was started in 1995 and employs modern techniques of cryopreservation. Organ procurement increased from 11 hearts in 1995 to 138 hearts in 2000. In the beginning of the experience, only 2 hospitals were using these valves, but this increased to 18 centers in 2000. Clinical experience at the major center includes 117 cases of the Ross procedure, 62 aortic homograft implantations, and 18 cases of mitral homografts. Five-year survival after the Ross procedure was 99.1%, and survival free from any kind of complication was 88.8%. No patients are on anticoagulants, and the incidence of thromboembolism was null. We conclude that auto- and homografts are probably the best alternative to aortic valve replacement for young patients in developing countries.
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Affiliation(s)
- F D da Costa
- Santa Casa de Misericórdia de Curitiba, Pontifícia Universidade Católica do Paraná, Brazil
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Ohye RG, Gomez CA, Ohye BJ, Goldberg CS, Bove EL. The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function. Ann Thorac Surg 2001; 72:823-30. [PMID: 11565665 DOI: 10.1016/s0003-4975(01)02814-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Ross procedure has been increasingly applied to neonates and infants. Addition of a modified Konno-type enlargement of the aortic annulus allows the application of this procedure to neonates and infants with significant annular hypoplasia. The potential for growth and the proven durability make the autograft an ideal aortic valve replacement. METHODS Between March 1993 and December 2000, 10 patients under 1 year of age underwent a Ross/Konno procedure at our institution (range, 2 to 349 days; median 16). All patients had severe to critical aortic stenosis. All patients required aortic annulus enlargement for size mismatch between the aortic and pulmonary valves. RESULTS There were no deaths at a median follow-up of 48 months (range, 1 to 74 months). All patients had none to mild aortic stenosis on Doppler echocardiography. Eight patients had a 0 to 1+ aortic insufficiency, 1 patient had a 2+ aortic insufficiency, and 1 patient had a 3+ aortic insufficiency. Aortic annular dilatation was not observed. Aortic sinus dilatation occurred initially (mean change in z-value: 0 to 12 months, +2.1) and then stabilized (mean change in z-value: 12 to > 36 months, +0.6). No patient required additional procedures for aortic valve disease. Two patients required three pulmonary allograft replacements. CONCLUSIONS The Ross procedure with a modified Konno-type enlargement of the aortic annulus is an excellent approach to aortic valve disease in the neonate and infant. The procedure can be accomplished with low morbidity and mortality, and low rates of reoperation. The pulmonary autograft demonstrates durability without developing aortic stenosis, aortic insufficiency, or progressive dilatation. Enlargement of the aortic annulus parallels somatic growth.
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Affiliation(s)
- R G Ohye
- Division of Pediatric Cardiovascular Surgery, University of Michigan School of Medicine, Ann Arbor 48109, USA.
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