| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Eur J Cardiothorac Surg 2004;26:661-662
© 2004 Elsevier Science NL
Letter to the Editor |
Department of Paediatric Cardiac Surgery, Alder Hey Hospital, Eaton Road, Liverpool L12 2AP, UK
Received 6 May 2004; accepted 17 May 2004.
* Tel.: +44-151-252-5635; fax: +44-151-252-5643
e-mail: drrajashahzad{at}hotmail.com
Key Words: Ross procedure • Pulmonary autograft • Autograft failure
Schmid and colleagues [1], and the editorial staff of EJCTS, deserve credit for carrying out and publishing an important study to address molecular mechanisms and signalling pathways for aneurysm formation in ascending aortic aneurysms and pulmonary trunk of patients with different aortic valve pathology undergoing an extended Ross procedure. The study is timely and the conclusion extremely significant as on one hand it validates the safety of Ross procedure in the presence of bicuspid aortic valve and on the other hand opens new avenues for research to determine the reasons for pulmonary autograft dilation after Ross procedure.
As the popularity of the Ross operation has grown over the years, so has the population of patients with a pulmonary autograft in the aortic position and a pulmonary homograft in the pulmonary position. Although results with the surgery have been encouraging [2–4] yet serious concerns regarding the consequences of trading one-valve disease for the possibility of two-valve disease have always tarnished the reputation of what is otherwise an excellent treatment option for children and adolescents with aortic valve disease. Autograft insufficiency is the leading cause of reoperation in Ross operation patients [3,4]. Several factors are implicated. Patient characteristics that predispose to autograft insufficiency and failure include a preoperative diagnosis of aortic insufficiency and the presence of a dilated aortic annulus. Endocarditis, inherent disease of the pulmonary valve and rheumatic heart disease have also been implicated [4]. Although a bicuspid aortic valve was thought to be a risk factor, increasing evidence is accumulating to suggest that perhaps all is not true about the association of bicuspid aortic valve and autograft failure [1–3]. Non-patient-related factors of autograft failure include technical inaccuracies and the learning curve of surgical expertise. Modifications in surgical technique have improved outcomes, including aortic annuloplasty to fix the size of the annulus and attention to tailoring the aorta to match the autograft [3].
Perhaps the single most important factor responsible for dilation of the pulmonary autograft is the technique of implantation of the autograft. It is suggested that the freestanding root replacement technique, almost universally accepted, exposes the thin and possibly vulnerable pulmonary artery wall to acutely imposed systolic blood pressure thereby predisposing it to dilation and progressive autograft regurgitation [5]. On the contrary, the subcoronary technique, less popular owing to being technically demanding, by retaining the patient's own aortic wall and the natural sinuses is thought to provide the best prospect for the valve's long term function [5].
Hence, there is a lot of substance in the conclusion of Schmid et al. [1] that perhaps there is much more involved in dilation of the pulmonary autograft than just histopathological and biomolecular mechanisms.
Footnotes
The authors of the original paper [1] were invited to comment on this Letter to the Editor and replied as follows: "We are most grateful for Mr Raja's comments and are in complete agreement with him. There is no need for a reply".
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
