Volume 133, Issue 6 , Pages 1645-1647, June 2007
Reversing the Ross operation: A new reoperation option for autograft failure
Article Outline
CTSNet classification: 35
In the late 1980s, Stelzer and Elkins1 popularized the Ross operation by simplifying it, achieving good and consistent results after autograft implantation as a full freestanding root. However, in the late 1990s, David and colleagues2 called attention to progressive dilatation of the autograft root that caused regurgitation and eventual failure. Prevalence of reoperation up to 25% at 10 years has been observed even in larger series.3
For patients with autograft dilatation and aortic regurgitation, surgical options include valve-sparing David reimplantation, composite graft (Bentall), or allograft root replacement. Most of these patients do not have an autograft-sparing procedure; rather, they have the autograft replaced and are left with an allograft remaining in the pulmonary position that is subject to future deterioration.
In this communication, we describe clinical and operative details of 3 patients from an initial experience of reversing the Ross operation by autograft excision and reuse in its native pulmonary position.
Clinical Summaries
Clinical and operative details of 3 male patients, all of whom originally had bicuspid aortic valve disease, are described in Table 1. Patient 3 had undergone pulmonary allograft dilatation and stenting 3 years after the Ross procedure.
TABLE 1. Patient clinical, operative, and outcome details
| Details | Patient No. | ||
|---|---|---|---|
| 1 | 2 | 3 | |
| Clinical | |||
 Age (y) | 37 | 28 | 67 |
| Time since Ross procedure (mo) | 138 | 77 | 73 |
| Neo-aorta/valve pathology | Aneurysm, 3+ AR | Aneurysm, 1+ AR | Dilatation, 4+ AR |
| Allograft/RVOT pathology | Moderate stenosis | Mild stenosis, 1+ PR | Severe stenosis |
| Original autograft technique | Root replacement | Root replacement | Root replacement |
| Operative | |||
| Aortic root implant | 27-mm composite, mechanical | 31-mm composite, mechanical | Allograft, 28 mm |
| Hypothermic circulatory arrest time (min) | 16 | 18 | 0 |
| Myocardial ischemic time (min) | 153 | 137 | 162 |
| CPB time (min) | 186 | 160 | 178 |
| Outcome | |||
| Postoperative PR | 1+ | 0 | 0 |
| Hospital stay (d) | 7 | 8 | 6 |
All patients had transesophageal echocardiography (TEE). After resternotomy, the right side of the heart and aorta were mobilized and cardiopulmonary bypass instituted. Induction with antegrade and retrograde cold blood cardioplegia, followed by retrograde cardioplegia delivered at 15-minute intervals and warm terminal cardioplegia, provided myocardial protection. Two patients required brief hypothermic circulatory arrest and retrograde cerebral perfusion for hemiarch replacement.
Presence of good autograft cusps was confirmed. Coronary buttons were excised, maintaining a rim of healthy tissue around the ostia. The autograft was carefully dissected out and excised from the left ventricular outflow tract (Figure 1, A). In all 3 cases, autografts had an approximately 1-cm-wide fibrous margin between the cusps and left ventricle, allowing excision with a 3- to 4-mm rim of tissue for reimplantation, while not compromising the left ventricular outflow tract. The previously scalloped autograft was refashioned with autologous pericardium (Figure 1, B).
Figure 1.
Pulmonary autograft reimplantation into the native position after the Ross procedure. A, Explanted autograft. B, Scalloped autograft refashioned with autologous pericardium. C, Reimplanted autograft before separation from cardiopulmonary bypass.
The pulmonary allograft was radically excised, leaving no allograft, inflammatory, or scar tissue behind.
The proximal anastomosis of a composite aortic root replacement or allograft root was completed in standard fashion and the coronary buttons anastomosed anatomically with continuous 5-0 polypropylene suture. The refashioned pulmonary autograft was reimplanted into the right ventricular outflow tract in anatomic orientation with continuous 4-0 monofilament sutures for both distal and proximal anastomoses. Finally, the aortic root implant was anastomosed to the distal ascending aorta or distal aortic graft with continuous 4-0 monofilament suture (Figure 1, C). After separation from bypass, TEE confirmed good valve function.
All patients had transthoracic echocardiography and computed tomography before hospital discharge.
Discussion
In patients who have had the Ross procedure, the method described in the present study addresses (1) pulmonary autograft dilatation with secondary aortic regurgitation and (2) possible long-term implications of an allograft in the pulmonary position. This technique achieved excellent clinical and echocardiographic results. Even when the autograft was dilated and its valve regurgitant, if leaflet structure was good, the downsized reconstructed autograft appeared suitable for reuse. Function of the pulmonary valve was excellent after the procedure. This is a long and technically demanding operation, but it was well tolerated by these patients, as evidenced by their smooth postoperative courses and short hospital stays.
For autograft dysfunction associated with dilatation, aortic root reimplantation according to David has been described.4 Although conceptually attractive, the amount of tissue surrounding the autograft, combined with an asymmetric appearance of autograft cusps at the time of the attempted David procedure, resulted in abandoning it on two previous occasions in our hands. However, technical feasibility of the David procedure in this setting has been demonstrated, and it remains one of the options discussed with the patient. One of the patients in this series declined this option. The ideal patient for the David procedure would have moderate autograft dilatation, central regurgitation, symmetric autograft cusps, and a perfect pulmonary allograft. Data demonstrating longevity and durability of the David reimplantation procedure after the Ross operation may never be more than anecdotal. The allograft aortic root replacement option for a failed Ross procedure without reuse of the autograft gives the patient two allografts with potential for degeneration and need for subsequent technically demanding reoperations.
Our own experience with reoperation after the Ross procedure now exceeds 30 patients. Two thirds of these reoperations have related primarily to autograft failure; in retrospect, many of these patients could have benefited from the reversal described. Patients have also expressed psychologic relief. At this early stage, we are hopeful that the reversal procedure is a good, durable option for many patients with a failed Ross procedure.
References
- . Pulmonary autograft: an American experience. J Card Surg. 1987;2:429–433
- Dilation of the pulmonary autograft after the Ross procedure. J Thorac Cardiovasc Surg. 2000;119:210–220
- . The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg. 2004;78:773–781discussion 773-81
- . Aortic root reimplantation for successful repair of an insufficient pulmonary autograft valve after the Ross procedure. J Thorac Cardiovasc Surg. 2002;124:1048–1049
PII: S0022-5223(07)00354-6
doi:10.1016/j.jtcvs.2007.01.056
© 2007 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
Volume 133, Issue 6 , Pages 1645-1647, June 2007
