Asian Cardiovasc Thorac Ann 2005;13:321-324
© 2005 Asia Publishing EXchange Ltd
Autologous Pericardial Valved Conduit for The Ross Operation
Taweesak Chotivatanapong, MD,
Choosak Kasemsarn, MD,
Chaiwuth Yosthasurodom, MD,
Pradistchai Chaiseri, MD,
Vibhan Sungkahapong, MD1,
Kriengkrai Hengrussamee, MD2
Cardiothoracic Surgical Division
1 Division of Anesthesiology
2 Division of Cardiology, Chest Disease Institute Nonthaburi, Thailand
For reprint information contact: Taweesak Chotivatanapong, MD Tel: 66 2 588 3119 Fax: 66 2 589 9321 Email: taweesak13{at}hotmail.com, Department of Cardiothoracic Surgery, Chest Disease Institute, Tivanonth Rd, Nonthaburi 11000, Thailand.
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ABSTRACT
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The feasibility and function of autologous pericardial valved conduit for right ventricular outflow tract reconstruction in the Ross operation were assessed. Between June 1997 and April 2002, 31 patients underwent this procedure at our institution; one was lost to follow-up. The other 26 males and 4 females were aged 17 to 60 years (mean, 36.6 years). Causes of aortic valve disease were infective endocarditis in 26 and rheumatic valve disease in 4. Mean follow-up was 16.7 months (range, 1–58 months). Preoperatively, 9 patients were in functional class II, 19 in class III, and 2 in class IV. Concomitant procedures included coronary artery bypass (1), mitral valve replacement (6), tricuspid valve replacement (1), and ventricular septal defect closure (1). Mean aortic crossclamp time was 199.4 min. There were 4 (13.3%) hospital deaths and no late death. Mean postoperative functional class was 1.17 with +0.36 aortic regurgitation, a peak gradient of 21.9 mm Hg (range, 6–59 mm Hg) across the conduit, and grade +0.96 pulmonary regurgitation. No conduit-related complication was detected. Use of autologous valved conduit for the Ross operation is feasible. Long-term follow-up is mandatory to assess durability.
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INTRODUCTION
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Aortic valve replacement with a pulmonary autograft (the Ross operation) has recently gained more attention as an alternative treatment for patients with aortic valve disease. It has been advocated as the preferred operation particularly in patients who are young and unsuitable for long-term anticoagulation. However, this operation has posed several problems due to the complexity of the technique and availability of homografts for right ventricular outflow tract (RVOT) reconstruction. To solve the problem of lack of homografts, we introduced the use of an autologous pericardial valved conduit for RVOT reconstruction. This report summarizes our early results.
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PATIENTS AND METHODS
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Between June 1997 and April 2002, 31 patients underwent the Ross operation using autologous pericardial valved conduit for RVOT reconstruction at the Chest Disease Institute. One patient was lost to follow-up and was excluded from the study. The other 26 males and 4 females were aged 17 to 60 years, with a mean age of 36.3 years. Follow-up ranged from 1 to 58 months, with a mean of 16.7 months. Aortic valve disease was mainly caused by infective endocarditis (26 patients). In the other 4 patients, it was due to rheumatic disease. Preoperatively, 21 patients were in New York Heart Association functional class III and IV, and 9 were in class II. Most patients had a moderately severe or severe degree of aortic regurgitation, only one had moderate aortic regurgitation. A total of 26 patients had an ejection fraction 
50%. The ejection fraction of the other 4 patients was 26–49%. Most patients had a pulmonary artery pressure below 60 mm Hg; 8 had a pulmonary artery pressure above 60 mm Hg. The mean peak gradient across the pulmonary valve was 6 mm Hg. Echocardiography was performed during the intraoperative and postoperative periods. Intraoperatively, transesophageal echocardiography was used routinely by the cardiac anesthetist to assess the function of the valve before and after the operation. Postoperative echocardiography was carried out by a cardiologist at intervals of 1, 3, and 6 months after the operation. The patients were followed up by the same group of cardiac surgeons at intervals.
The chest was opened by a median sternotomy incision. Prepericardial fat and tissues were carefully dissected. A single large piece of pericardium was excised, extending from the level of the aortic arch to the diaphragmatic region, and laterally 2 cm anterior to the phrenic nerve. It was treated in 0.65% glutaraldehyde solution for 10 min and rinsed 3 times in 0.9% saline solution for 5 min. Construction of the valved conduit was started by assessment of the size of the native pulmonary artery and selection of the appropriate size of valve mould. The pericardium was cut into 2 pieces: one for a valve cusp patch according to the selected size of the valve mould, and the other for a conical patch. The conical patch was conformed to the size of the native RVOT and pulmonary artery, including the sinus of Valsalva. The valve cusp was sutured to the conical patch with 5/0 Prolene (Ethicon, Somerville, NJ, USA) using a simple interrupted suture technique starting from mid cusp toward the commissure. After completion, the conical patch was rolled over and closed using a 5/0 Prolene running suture to accomplish the autologous pericardial valved conduit. Competency of the valved conduit was tested by flushing 0.9% saline into the conduit at the end of the procedure.
Cardiopulmonary bypass was instituted with moderate hypothermia (28°C to 30°C) and cold blood cardioplegia. Warm terminal blood reperfusion was given prior to aortic declamping. The pulmonary autograft was implanted using a total root replacement technique in all cases. Proximal anastomosis was performed with 2/0 Ethibond (Ethicon, Somerville, NJ, USA) using the interrupted mattress suture technique. A piece of pericardial felt was incorporated into the anastomosis. The coronary artery stumps were anastomosed to the autograft with 5/0 Prolene using a simple running suture. Distal anastomosis of the autograft to the aorta was completed with a continuous 4/0 Prolene suture. Concomitant operative procedures included coronary artery bypass grafting (1), mitral valve replacement (6), tricuspid valve replacement (1), and closure of a ventricular septal defect (1). The mean cardiopulmonary bypass and aortic crossclamp times were 262.36 and 199.4 min, respectively. The mean amount of blood transfused postoperatively was 6.3 units.
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RESULTS
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There were 4 hospital deaths (mortality, 13.3%). One patient died suddenly one day before discharge after an uneventful postoperative course. Two patients had low cardiac output and died on the 1st and 3rd postoperative days. The other death was due to perioperative myocardial infarction which resulted in sepsis and multi-organ failure. There was no late mortality. Problems related to right coronary implantation occurred in 2 patients. One needed immediate revision of the proximal anastomosis intraoperatively and survived. The other needed coronary artery bypass after cardiopulmonary bypass had been discontinued. He suffered a myocardial infarction and consequently died. Other complications were bleeding in 5 patients and arrhythmia in 2. Of the 26 survivors, postoperative New York Heart Association functional class improved markedly compared to the preoperative period (Table 1
). Echocardiographic data obtained from 25 survivors at a mean of 11.8 months postoperatively (range, 1–58 months) showed favorable results. Aortic regurgitation improved substantially postoperatively (Table 2). Data on the valved conduit obtained from 18 patients showed the mean peak gradient across the conduit was 21.9 mm Hg (range, 6–59 mm Hg). Two patients had a mean peak gradient > 40 mm Hg (59 and 45 mm Hg) at years 2 and 5 postoperatively. Pulmonary regurgitation data are shown in Table 3.
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DISCUSSION
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Aortic valve replacement with a pulmonary autograft was first introduced in 1967 but widespread use of this operation was delayed for many years because of the complexity of the surgical technique and the need for RVOT reconstruction. However, reports of excellent outcomes and hemodynamic results from many studies rapidly reawakened interest in this operation.1–3 Although the technical problems of the Ross operation have largely been solved, RVOT reconstruction still poses a dilemma in the choice of conduit or the availability of a homograft, which is currently the conduit of choice. In many areas of the world including Thailand, the shortage of homografts remains an important limiting factor in the application of the Ross operation. Several alternative approaches for RVOT reconstruction have been reported and investigated, ranging from a simple autologous pericardial tube to a stentless xenograft or tissue-engineered valve.4–6
Our interest in the use of the autologous pericardial valved conduit was based primarily on the results of aortic valve replacement using autologous pericardium.7 Our previous study confirmed the encouraging midterm results of this technique.8 It was found that the autologous pericardial valve could function satisfactorily, even in a highly stressed area such as the aortic valve position. Incorporation of valve cusps into the simple pericardial tube for RVOT reconstruction should result in an improved hemodynamic effect, provided the conduit functions satisfactorily without significant stenosis or regurgitation. This has been shown in our study by the low pressure gradient and satisfactory competency of the valve in the majority of cases. Two patients whose peak pulmonary valve gradients were above 40 mm Hg at 2 and 5 years postoperatively were closely followed up because of the possibility of re-operation. In addition, we tailored our conduit in such a way that it would perform the function of the sinus of Valsalva, which is important for the durability of the valved conduit, as shown by Kumar and colleagues.9 Excellent long-term results of autologous pericardial valved conduit for RVOT reconstruction in congenital heart surgery were reported by Schlichter and colleagues.10 Recently, indications for the Ross operation have been extended to cover infective endocarditis. Encouraging results of this operation in patients with various degrees of infective processes have been reported.11–12 Our results confirm this favorable outcome as the majority of our patients had infective endocarditis. However, in young rheumatic patients, we would limit the use of this operation to those who have problems with anticoagulant or drug compliance, as the long-term outcome of the Ross operation in such patients is still uncertain.13–14
Based on our early results, it was concluded that the use of an autologous pericardial valved conduit for RVOT reconstruction in the Ross operation is feasible and reproducible. The function of the conduit was satisfactory and stable over the period of the study. Furthermore, the conduit is cheap, readily available, and can be produced in an appropriate size for the individual patient in virtually all situations. Therefore, it should be considered for RVOT reconstruction in the Ross operation when a homograft is not available. However, long-term follow-up is mandatory to confirm the durability and safety of this conduit.
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REFERENCES
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- Stelzer P, Elkins RC. Pulmonary autograft: an American experience. J Card Surg 1987;2:429–33.[Medline]
- Elkins RC, Santangelo K, Stelzer P, Randolph JD, Knott-Craig CJ. Pulmonary autograft replacement of the aortic valve: an evolution of technique. J Card Surg 1992;7:108–16.[Medline]
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- Ross DN. Options for right ventricular outflow tract reconstruction. J Card Surg 1998;13:186–9.[Medline]
- Konertz W, Sidiropoulos A, Hotz H, Borges A, Baumann G. Ross operation and right ventricular outflow tract reconstruction with stentless xenografts. J Heart Valve Dis 1996;5:418–20.[Medline]
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ABSTRACT
INTRODUCTION
