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Eur J Cardiothorac Surg 2002;21:470-473
© 2002 Elsevier Science NL

Dilatation of the autograft root after the Ross operation

^a Department for Cardiac and Thoracic Surgery, University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
^b Department of Medical Computer Sciences, University of Vienna, Vienna, Austria

Received 27 September 2001; received in revised form 20 December 2001; accepted 23 December 2001.

* Corresponding author. Tel.: +43-1-40400-5620; fax: +43-1-40400-5640
e-mail: paul.simon{at}univie.ac.at

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 
Objective: Structural differences of the pulmonary root may predispose it to progressive dilatation in the systemic circulation after the Ross operation. We identified the incidence and risk factors of pulmonary autograft root dilatation. Methods: One hundred and seven adult patients (mean age of 36±11 years) were followed after the Ross operation since 1991 including an echocardiogram within 3 months of surgery and yearly clinical assessment and echocardiography. The autograft was measured at the maximum diameter of the sinus (SV) and aortic insufficiency (AI) assessed. A SV of >37 mm was considered as root dilatation and the incidence over time was calculated using the Kaplan–Meier method. Clinically relevant dilatation was defined as a root diameter of >42 mm. In addition, we determined the percentage change of the sinus diameter between the early and latest echocardiogram. Furthermore we tested the influence of patient variables and risk factors on dilatation. Results: By 1 year, dilatation was found in 21 patients (20%). The SV was >42 mm in eight patients (7%). By 7 years, only 45% of patients were free of dilatation. Eleven patients (10%) had a SV of >42 mm. Increase in SV was time related and linear. However, 90% of patients showed <25% dilatation during follow-up. Time from operation, early SV diameter, male gender and surgical technique were identified as significant risk factors of dilatation. However, dilatation has not lead to reoperation due to aneurysm formation or development of significant AI. Conclusions: We conclude that time dependent autograft root dilation occurs but does not cause an increase in AI and need for reoperation up to 7 years. These findings warrant the pursuit of the concept of the Ross operation in young patients who regain excellent functional status and life style without anticoagulation.

Key Words: Valves • Aorta • Ross operation • Autograft • Dilatation

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 
Excellent short- and mid-term results have been demonstrated for aortic valve replacement with the pulmonary autograft with low rates of valve related deaths and complications [1–4] and physiologic hemodynamic performance at rest and during exercise [5]. However, there is concern that the pulmonary autograft might dilate in the high pressure systemic circulation [6]. In patients with bicuspid aortic valves, dilatation of the aortic root may occur even in the absence of a hemodynamically relevant valve lesion [7,8]. The aortic root shows an increased fragmentation pattern of the elastic fibers in patients with bicuspid valves. In these patients, this was also observed in the pulmonary root and it was suggested to cause late dilatation [9]. However, there are considerable differences in wall structure between the aortic and pulmonary root even in patients with tricuspid valves. The media is significantly thicker in the aorta and elastic fibers show highly variable degrees of fragmentation in the pulmonary root [10]. We investigated in a prospective study the incidence and risk factors of pulmonary autograft root dilatation.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 
Since 1991, 107 adult patients were 30-day survivors of the Ross operation. The combined in hospital and 30-day mortality is 1.9%. We have reported our results and surgical techniques previously [4,11]. Briefly, the Ross operation was performed with standard cardio-pulmonary bypass and moderate hypothermia of 28–32 °C. Myocardial protection was achieved with combined ante- and retrograde cold blood cardioplegia. The autograft was implanted as a full root intra-annularly with re-implantation of the coronary ostia. The autograft was supported by wrapping with a vicryl net, the remnants of the native aorta or a combination of both in 39 patients to prevent early dilatation. The use of autograft root support techniques depended on the implanting surgeon rather than on specific pathologies or root dimensions. The pulmonary root was in all cases replaced with a pulmonary homograft.

The mean age of the patients was 36±11 years (range, 18–58 years). There were 79 male patients (74%) and 28 female patients (26%). The underlying valve pathology and hemodynamic lesions are shown in Table 1.

The autograft was measured in the parasternal long-axis view of the 2D-echocardiographic image at end-diastole at the level of the sinus of Valsalvae. AI was graded semi-quantitatively using color Doppler (grade 0=no insufficiency; grade I=mild; grade II=moderate, hemodynamically non-significant; grade III and IV=hemodynamically significant insufficiency). At the level of the sinus, a diameter greater than 37 mm was determined as the threshold for root dilatation based on standard echocardiographic values for the aortic root [12]. Clinically important dilatation was defined as a root diameter greater than 42 mm.

Patients were also analyzed in regard to the percentage progression of the sinus to identify patients who have progressive dilatation independent of the initial size of the autograft after surgery. Risk factors thought to be important in the potential development of dilatation were evaluated.

2.1. Statistical analysis
Data are described with mean and standard deviation, when applicable, or otherwise with median, minimum and maximum. Estimates of dilatation-free survival, defined as a diameter of not more than 37 mm, was calculated using the method of Kaplan and Meier and the resulting estimates are graphically presented. Group comparisons of initial sinus were tested using the Student's t-test.

It was assumed that the importance of changes in diameter depends on the initial value and therefore the percentage changes from the first diameter measurements were calculated. If there was no measurement within the first 3 months after surgery, the patient was withdrawn from further analysis. The effect of risk factors on percentage changes of the diameter were evaluated by analysis of covariance. The following risk factors were included in the model: age at surgery; sex; autograft support technique with wrapping; valve pathology; sinus diameter at early measurement; and time since surgery. The effect of continuous covariates is described by the slope of the regression-line and the influence of categorical covariates is described by least-square means and their standard error.

All tests are two-sided and statistical significance was assumed at P0.05.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 
The median follow-up was 2.5 years, with a range of 10 months to 8.3 years. The autograft root diameter increased from a mean of 34.5±4.9 mm early to 36.8±5.1 mm at the last follow-up. Eleven patients (10.2%) had an autograft root diameter greater than 42 mm. The autograft sinus in women is significantly smaller initially than in men, 30.6±4.5 vs. 35.6±4.4 mm (P=0.0005). There is clear evidence of a time dependent dilatation of the autograft root as can be seen in the graph depicting the Kaplan–Meier analysis of freedom from dilatation greater than 37 mm (Fig. 1) . At 1, 2, 5 and 7 years, freedom from dilatation was 80, 62, 48 and 45%, respectively. The sinus increased by a mean of 7.6% from the early to the last follow-up. The amount of dilatation was less than 25% in 90% of patients. The calculated mean rate of dilatation is 1.4 percentage points per year.

View larger version (25K): [in this window] [in a new window]   Fig. 1. Freedom from autograft root dilatation is shown and was 80, 62, 48 and 45% at 1, 2, 5 and 7 years, respectively. Number of patients at risk is indicated in the graph up to 7 years.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 
The Ross operation can be performed safely and with excellent hemodynamic results at rest and during exercise [1–5]. The procedure is considered the state of the art operation in young, physically active patients by many surgeons since the alternative of a mechanical valve prosthesis requires life-long anticoagulation with its inherent risks [13]. Biologic prostheses do not offer a good alternative due to rapid degeneration in the young [14,15].

However, there is concern that the pulmonary autograft may dilate in the systemic circulation with progressive aortic regurgitation. In addition, aortic valve disease especially the presence of a bicuspid aortic valve may be associated with abnormalities of the ascending aortic root structure [7,8]. It has been suggested that in some of these patients these structural abnormalities are not limited to the ascending aorta but a higher degree of elastic fiber fragmentation and degenerative changes are also seen in the pulmonary root [9]. These structural changes have been implicated in the development of progressive dilatation of the autograft root.

In our study with a follow-up of more than 8 years, we have observed dilatation of the autograft root. After 7 years, only 45% have a sinus diameter of less than 37 mm, the threshold for echocardiographic dilatation. However, in 90% of patients this dilatation was less than 25%. We did not find progressive development of clinically relevant aortic regurgitation. This is in accordance with the findings of Carr-White et al. [10] who found in their study no dilation of the sinus of more than 20% during a 4 year follow-up with no significant aortic regurgitation in their patients. They observed significant differences in aortic and pulmonary root structure and mechanical behavior as well as signs of adaptation of the pulmonary root to higher pressures.

An important risk factor for dilatation observed in our study was the time from surgery, with an annual rate of dilatation of 1.4 percentage points. Since we did not find that dilatation up to 25% of the initial diameter was associated with progressive AI, considerable tolerance of the pulmonary root may be assumed. Male gender was also found to be a risk factor for dilation with an increase in diameter of 9.2% in men vs. 0.9% in women when they have the same underlying initial sinus. The reason for this remains unclear. Whether a higher stroke volume in men and the associated increase in autograft stretch may contribute to this finding needs to be determined. Technical considerations seem also to be of importance. We have used strict intra-annular implantation of the pulmonary root. The aortic annulus is carefully evaluated especially in patients with AI and bicuspid valves [11] and reduced if there is mismatch to the pulmonary root. The sino-tubular junction is also carefully measured and reduced if ascending aortic ectasia is present in order to avoid distension of the pulmonary root at this level which may lead to primary valve regurgitation or may reduce the overlap of the leaflets and hence the tolerance to late dilation. In a subset of 39 patients, we have employed root stabilizing techniques namely wrapping of the root with a vicryl net or stabilization of the non-coronary sinus with the remnant of the ascending aorta or a combination of the two techniques. Failure to use such techniques was associated with a 7.2% increase in diameter as opposed to only 2.8% in patients in whom a stabilization technique was used. These data support our view that support of the autograft sinus may prevent dilation and such techniques are now routinely used. Other series in which AI developed during follow-up may have not employed annulus fixation, adjustment of the sino-tubular junction or root stabilization techniques which may explain our finding of stable valve performance of the autograft up to 8.2 years. This may also explain why AI as the primary hemodynamic lesion and bicuspid valve were not found to be significant risk factors in our series of patients.

	5. Limitations

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 
Patients with a single measurement during follow-up were included in the Kaplan–Meier analysis. It cannot be ruled out that some of the patients determined as dilated already had a sinus diameter greater than 37 mm after surgery. Nevertheless, there is a clearly time related increase in the number of patients exhibiting dilatation. In addition, time from surgery was also found as a significant risk factor for dilatation in the second analysis in which only patients were included who had at least two echocardiograms, one early and one late.

No histologic material for evaluation is available to determine whether patients with more pronounced dilatation show more severe degenerative changes of the pulmonary artery at the time of surgery.

Subcoronary implantation and the inclusion technique were not used. Therefore, comparisons with these techniques cannot be drawn from our study.

	6. Conclusions

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 
We conclude from our data that dilatation of the autograft root occurs in a time dependent fashion after the Ross operation. Dilatation is less than 25% of the initial diameter in the majority of patients. Valve function is stable up to 8 years. Careful consideration of technical aspects may contribute to the excellent long-term performance of the autograft. We continue to recommend the Ross operation as the primary procedure of choice in young patients.

	Footnotes

 
Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Limitations 6. Conclusions References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Reinhard Moidl Ernst Wolner Paul Simon Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Simon-Kupilik, N. Articles by Simon, P. Search for Related Content PubMed PubMed Citation Articles by Simon-Kupilik, N. Articles by Simon, P. Related Collections Congenital - acyanotic Valve disease