The Ross procedure: Is it the ideal operation for the young with aortic valve disease?

BACKGROUND: Aortic valve prosthesis with adequate hemodynamic performance should allow more complete left ventricular mass regression and normalize left ventricular function. This possibly affects long-term prognosis after aortic valve replacement. OBJECTIVE: Assessment of hemodynamic performance of pulmonary autograft in the aortic position and the regression of left ventricular mass after the Ross procedure. METHODS: Between May 1995 and March 1996, 45 patients with mean age of 27.1 years underwent a Ross procedure. Doppler echocardiography and cardiac catheterization were performed on all patients before hospital discharge to evaluate the hemodynamic performance of auto- and homografts, as well as to evaluate left ventricular mass and function. Fourteen patients with follow-up longer than six months were submitted to dobutamine stress echocardiography to study the hemodynamic performance of auto- and homografts during exercise. RESULTS: Hospital mortality was 6%. After a mean follow-up of 12.8 months (1-23 months) there was one late sudden death. No valve-related event was observed during this period. Immediate and late hemodynamic performance of the pulmonary autografts were normal with an average mean gradient of 1.8 +/- 0.6 mmHg and an average maximum instantaneous gradient of 2.9 +/- 0.9 mmHg. Valvular insufficiency was insignificant. Even during exercise, gradients did not increase significantly with an average mean gradient of 4.3 +/- 2.5 mmHg and an average maximum gradient of 10.4 +/- 6.1 mmHg. Homografts used for right ventricular reconstruction showed excellent immediate hemodynamic performance. However, at late follow-up an increase in flow speed was observed with an average to mean gradient of 10 +/- 7.1 mmHg at rest and 26 +/- 13.2 mmHg during exercise. Left ventricular mass index was normal at rest and during exercise in the majority of patients. CONCLUSION: Given the normal hemodynamic function of pulmonary autografts, the reduction of ventricular mass and normalization of left ventricular function, in addition to the excellent late follow-up of the patients, the Ross procedure is considered the operation of choice for young patients requiring aortic valve replacement.

Myocardial revascularization with the radial artery: a clinical and angiographic study.

BACKGROUND: It has been well documented that the use of the internal thoracic artery yields better long-term patency rates than saphenous vein grafts for coronary artery bypass grafting. This knowledge has prompted surgeons to use other arterial conduits such as the radial artery. METHODS: Between April 1994 and January 1996, radial artery grafts were used in 83 patients (mean age, 54.6 years) undergoing myocardial revascularization. All patients received diltiazem, 80 mg orally three times daily. Angiographic studies were performed in the early post-operative period in 61 patients, and 6 to 19 months later in 12 patients. RESULTS: There were four hospital deaths (4.8%), none of them due to cardiac causes. Perioperative myocardial infarction was observed in 3 patients, 1 related to a radial artery graft occlusion. Of 61 grafts studied early, 59 were patent (96.7%), but two grafts showed diffuse spasm. Twelve patients had a second angiogram after a mean interval of 8.7 months, and all grafts were patent. One patient who had a diffuse spasm at the early study had recurrent symptoms, and repeat angiogram showed further narrowing of the graft (string sign). CONCLUSIONS: Our results suggest that with proper care, the radial artery may be used for coronary artery bypass grafting with good early results. Long-term follow-up and angiography studies will be needed to establish the merit of the radial artery as a graft for coronary artery operations.

Early surgical results in the treatment of endomyocardial fibrosis. A Brazilian cooperative study.

This report summarizes the surgical experience and early results obtained at four surgical centers in the northeast and south of Brazil. From December 1977 to September 1986, 95 operations were performed on 93 patients, ages 11-59. Bilateral lesions occurred in 42 patients, right lesions in 39, and left lesions in 12. Ventricular decortication and removal of thrombi were performed in all. In right-sided lesions, the tricuspid valve was substituted by a bioprosthesis in 34 cases, and substituted by a tilting disk valve in 1 case. In 4 patients, the valve could be preserved. The left-sided lesions led to valve substition by a bioprosthesis in 11 cases, and preservation of the valve in 1. The bilateral lesions needed bioprosthesis in the mitral position in 37 patients, and a disk valve in 2. In these 39 instances, the valvular procedure was insertion of a tricuspid bioprosthesis. Three tricuspid and three mitral plasties were performed. The overall mortality was 20% (26.2% for bilateral lesions, 14.6% for the right-sided lesions, and 20% for the left-sided lesions). The main cause of death was low cardiac output. Aside from a variable degree of right and left ventricular failure, many other non-fatal complications clouded the postoperative course. Complete AV blocks occurred in 10 cases, with the need for permanent pacing in 7 survivors. The mortality and morbidity in the present series is in keeping with the results reported in current literature. Regarding the advanced stage of their patients' disease, the authors agree with the recommendation for earlier surgical intervention.