Eur J Cardiothorac Surg 2007;31:127-128. doi:10.1016/j.ejcts.2006.10.005
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
A modified Ross operation to prevent pulmonary autograft dilatation
Bansi Koula,*,
Faleh Al-Rashidia,
Misha Bhata,
Carl Meurlingb
a Cardiothoracic Surgery, University Hospital Lund, 221 85 Lund, Sweden
b Cardiology, University Hospital Lund, 221 85 Lund, Sweden
Received 6 July 2006;
received in revised form 2 October 2006;
accepted 3 October 2006.
* Corresponding author. Tel.: +46 703491649; fax: +46 46158635. (Email: bansi.koul{at}skane.se).
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Abstract
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A modification in Ross operation is described in which the free-standing pulmonary autograft root is suspended in a Dacron prosthetic vascular jacket with a view to prevent dilatation of the neo-aortic root. In a group of 13 patients operated consecutively using this technique, there was no significant increase in the diameters of the neo-aortic root after a mean 16-month follow-up. Aortic valve function remained also satisfactory.
Key Words: Adult • Autograft • Aortic valve • Heart valve • Ross operation
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1. Introduction
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Significant pulmonary autograft dilatation can occur as early as 7–10 days after the Ross operation with a further significant increase at the 1 year follow-up [1–3]. The mean rate of dilatation is estimated at 1.4 percentage points per year or less [4,5]. External stabilization of the neo-aortic annulus [6] and the neo-sino tubular junction [5,6] with synthetic materials appears to prevent dilatation at the respective sites, but dilatation of the neo-aortic sinuses of Valsalva continues to remain an unsolved problem following the conventional Ross operation. To address this problem, we modified our conventional Ross operation technique [7], as follows.
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2. Technique
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The entire pulmonary autograft was supported externally with a Dacron vascular prosthetic jacket—DVPJ (Vascutek-Gelweave, Vascutek Ltd., Renfrewshire, PA4 9 RR, Scotland) about 4 mm larger than the internal diameter of the pulmonary autograft annulus as measured intraoperatively. The pulmonary autograft annulus was suspended proximally from DVPJ with isolated sutures at mid-cusp level to three equidistant points on the DVPJ. The native aortic annulus was downsized to match the internal diameter of the pulmonary autograft. The pulmonary autograft together with the DVPJ were sutured in an anatomical position to the aortic annulus in a horizontal plane and at a level corresponding to the bottom of the excised aortic valve cusps using 4-0 Ethibond sutures (Ethicon, Johnson & Johnson Intl., Belgium) (Fig. 1
). Care was taken to align the neo-aortic left and right coronary artery cusp bottoms to the origin of the left and right coronary arteries, respectively. The length of the DVPJ was tailored in a stretched state to match the height of the pulmonary autograft. Distally, the DVPJ was now incised vertically for 4–6 mm at the site corresponding to the left coronary artery anastomosis and a rhomboid shaped window, slightly larger than the size of the coronary artery button, was created in the vascular prosthesis to allow the passage of the left coronary artery (Figs. 1 and 2
). After completion of the left coronary artery anastomosis, the pulmonary autograft together with the DVPJ were anastmosed with the distal ascending aorta using 4-0 Prolene (Visi-Black, Ethicon Inc., NJ, USA). During the latter anastomosis, the distal circumference of the DVPJ was reduced at the site of the left coronary anastomosis by excising 6–8 mm Dacron from the superior margin of the left coronary window and thereby converting the rhomboidal shaped window to a square shape (Fig. 1). A similar reduction in the distal DVPJ circumference was also made, if and when needed, in the superior margin of the right coronary artery window (Fig. 2). This reduction in the distal circumference of the DVPJ compensates for the oversizing of the DVPJ at the neo-sinotubular junction (STJ). The site of the right coronary artery anastomosis on the pulmonary autograft was selected after filling the aortic root with cardioplegia and the right ventricle with venous blood in order to prevent kink in the vessel (Fig. 2).
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Fig. 1. Dacron vascular prosthetic jacket (DVPJ) is tailored for external stabilization of the entire pulmonary autograft and two rhomboid shaped windows have been excised from the DVPJ corresponding to the passage of left and right coronary arteries. Final square shape of the left coronary windows after excision of 6–8 mm transverse strips of the Dacron from the superior margins which reduces the diameter of the DVPJ at the sino-tubular junction.
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Fig. 2. The prosthetic jacket with two rhomboid shaped windows corresponding to the passage of left and right coronary arteries (inset). Anterior height of the prosthetic jacket is slightly longer (inset). Modified Ross operation completed with interposition of a pulmonary homograft in the right ventricular outflow tract (main figure). Note the final square shape of the right coronary window (main figure).
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3. Results
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Thirteen consecutive patients were operated on with the modified Ross technique from April 30, 2003 to January 11, 2005. The mean age of the patients was 35 years (range: 22–50 years). No significant perioperative morbidity was observed and all patients are alive and doing well. The follow-up was 100% complete. The morphology of the neo-aortic sinuses and the STJ was not affected by the modification (, screen shot 1). The modified technique did not interfere with the aortic valve function and the size of the aortic annulus was adequate (, screen shot 2). The diameters of the neo-aortic annulus, neo-sinuses of Valsalva, and neo-STJ did not increase after a mean follow-up of 16 months (range: 5–24 months).
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4. Discussion
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Our present experience with the modified Ross operation includes the initial learning curve and our early postoperative results compare favorably to those with the conventional technique [7]. The modified technique prevented dilatation of the entire neo-aortic root while maintaining the morphology of the neo-sinuses of Valsalva and the neo-sinotubular junction. Therefore, our modification may confer an additional advantage over the modification suggested by Slater et al. [8]. In the later part of the evolution of the technique, the anterior half of the pulmonary autograft distal to the level of the commissures was left intact and DVPJ matched to the given height of the autograft (Fig. 2). This provides flexibility in the placement of the right coronary artery anastomosis. The use of DVPJ as suggested in this technique is tailor-made for the individual pulmonary autograft because pulmonary autografts vary significantly in size depending upon the basic aortic valve pathology [7]. Further, all degrees of pulmonary-aortic annulus mismatches are amenable to the modification after appropriate downsizing of the native aortic annulus.
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Appendix A
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Supplementary data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ejcts.2006.10.005.
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Footnotes
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\#9734; This paper has been presented at The Aortic Surgery Symposium XI, New York, USA, April 27–29, 2006.
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References
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Abstract
1. Introduction
