Behavior of the pulmonary autograft in systemic circulation after the Ross procedure.

OBJECTIVE: The purpose of this study was to evaluate performance in systemic circulation following pulmonary autograft aortic root replacement by means of serial postoperative echocardiographic studies. METHODS: From November 1997 to November 1999, 30 patients (21 males, 9 females) with a mean age of 29.97 +/- 12.97 years (age range 6-54 years) underwent pulmonary autograft aortic root replacement. Seven of these patients (23.33%) were less than 15 years old. Postoperative echocardiographic measurements of the neo-aortic root were performed within three months of operation, at six months, one year, and annually thereafter. Analysis of this study includes 22 patients with at least three months of follow-up. RESULTS: Operative mortality was 0%. Compared with preoperative values, the mean autograft annulus diameter exhibited an increase of 8.44% in the first month (1.44 +/- 0.22 cm/m2 vs. 1.55 +/- 0.21 cm/m2, p = 0.0101). An additional aortic annular dilation of 11.33% from baseline preoperative values was observed within the first year (1.41 +/- 0.15 cm/m2 preoperatively vs. 1.57 +/- 0.22 cm/m2, p = 0.0449). After the immediate postoperative period, the pulmonary autograft seemed to adapt to systemic circulation, and there were no differences in aortic annular size between 1-3 months after surgery and the 18-21 month follow-up period (1.60 +/- 0.18 cm/m2 vs. 1.60 +/- 0.27 cm/m2, n = 10). Diameter increase was not associated with the presence of aortic regurgitation. Mean neo-aortic maximal gradient was 7.85 +/- 5.59 mm Hg (3-29 mm Hg). There was a significant decrease in left ventricular size three months after surgery (50.71 +/- 10.20 mm preoperatively vs. 44.98 +/- 7.29 mm, p = 0.0491 in aortic stenosis patients and 68.50 +/- 8.39 mm vs. 59.04 +/- 9.21 mm, p = 0.0017 in aortic insufficiency patients). CONCLUSIONS: Pulmonary autograft annulus increases up to the first year after the Ross procedure but does not appear to progress beyond that time. The pulmonary autograft allows optimal hemodynamic performance without causing substantial aortic regurgitation, thereby permitting normalization of left ventricular dimensions and improvement of left ventricular function early in the postoperative period.

Left ventricular remodeling after pulmonary autograft replacement of the aortic valve (Ross operation).

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) with a pulmonary autograft is an alternative treatment for young patients with aortic valve disease. Superior hemodynamic performance of the pulmonary autograft, and impact on parameters of left ventricular function were analyzed. METHODS: Thirty patients (21 males, nine females; mean age 29.97+/-12.29 years; range: 6-54 years) underwent a Ross procedure between November 1997 and November 1999. Seven patients (23%) were children (aged <15 years). In total, 22 patients were analyzed; each had at least three months follow up. Eleven patients had predominant aortic stenosis (AS), and 11 had aortic insufficiency (AI). RESULTS: There were no operative deaths. Two patients developed severe insufficiency, and the autograft was replaced with a mechanical valve. Pre- and postoperative echocardiograms were reviewed. The mean neoaortic maximal gradient was 7.85+/-5.59 mmHg (range: 3-29 mmHg). AS patients showed reduced interventricular septal (IVS) thickness at one month (from 13.27+/-3.69 to 11.60+/-2.44 mm; p = 0.0165) and 18 months after surgery (p = 0.0104). Left ventricular posterior wall (LVPW) thickness was reduced from 12.04+/-3.75 to 9.48+/-2.47 mm (p = 0.0338) at one month and 18 months (p= 0.0128) after surgery. The left ventricular end-diastolic internal dimension (LVIDd) decreased from 50.71+/-10.20 to 44.98+/-7.29 mm (p = 0.0491) at one month after surgery. In AI patients, LVPW and IVS thicknesses showed no significant variation, and LVIDd was decreased at one month (from 68.50+/-8.39 to 59.04+/-9.21 mm; p = 0.0017) and 18 months (p = 0.0229) after surgery. Left ventricular end-systolic internal dimension (LVIDs) decreased from 44.06+/-6.39 to 39.03+/-7.99 mm (p = 0.0081) at three months after surgery. Left ventricular mass index (LVMI) in the AS group decreased from 179.01+/-62.26 to 115.74+/-37.62 g/m2 (p = 0.0021) at one month after surgery, and at 18 months was normal, with a decrease from 208.77+/-32.89 to 95.89+/-28.82 g/m2 (p= 0.0003) (n = 5). In the AI group, LVMI decreased from 186.25+/-85.21 to 140.58+/-62.02 g/m2 (p = 0.0011) at one month after surgery, and at 18 months from 217.70+/-98.02 to 146.73+/-84.55 g/m2 (p= 0.0131) (n = 5). CONCLUSION: The pulmonary autograft procedure can be used safely to replace the aortic valve, and allows optimal hemodynamic performance, with no significant aortic regurgitation. The Ross procedure results in normalization of left ventricular dimensions and improvement of left ventricular function early in the postoperative period.

[Aortic valve replacement with pulmonary autograft (the Ross procedure) in adult and pediatric patients]. / Sustitución valvular aórtica con autoinjerto pulmonar (operación de Ross) en pacientes adultos y pediátricos.

Aortic valve replacement with pulmonary autograft was first performed by Donald Ross in 1967. Initially, the procedure was not widely accepted, by Cardiologists and Cardiac surgeons fundamentally due to its complexity and demanding surgical technique, and because innumerous series two cardiac valves were at risk. The results published in the last 10-15 years established the pulmonary autograft as one of the best methods of aortic valve replacement, especially in pediatric patients and young adults. In the present article, we reviewed present indications and contraindications, and our clinical experience with 26 patients (pediatrics and adults). Analysis of the first 22 the patients with a minimum of 6 months of follow-up (180-620 days) was performed. Follow-up is complete (100%). Mean age was 31.4 +/- 12.6 years. Five patients were pediatrics (<= 14 years). Three patients (11%) with previous percutaneous procedures and 4 patients (14%) with previous surgical procedures. There was no early or late mortality. In the last follow-up, 19 of 22 (86.36%) had no autograft insufficiency (>= grade 1), and in one patient it was moderate (grade 2). The 2 remaining patients developed severe autograft insufficiency (grade 4) and were reoperated on, with satisfactory postoperative outcome. Mean maximal gradient was 7.85 +/- 5 mmHg at 18 months (3-29). Patients with preoperative aortic stenosis showed a significant reduction in myocardial mass index (208.7 +/- 32 a 95.8 +/- 28.8 g/m2) at 18 months. In these patients, septal and posterior wall thickness decreased significantly, in the first month. Two pediatric patients have developed transpulmonar gradient > 50 mmHg. One of them underwent successful stent implantation. We have not observed significant homograft insufficiency in any of our patients. All our patients remain asymptomatic (functional class I) without medical treatment. We have not observed either thromboembolic or haemorrhagic episodes, nor endocarditis. No patient is receiving anticoagulants. Clinical and echocardiographic mid term results in pulmonary autograft and homograft in our series, are excellent after the Ross procedure.

[Aortic valve replacement with a pulmonary autograft (the Ross operation) in adult and pediatric patients. A preliminary study]. / Reemplazamiento valvular aórtico con autoinjerto pulmonar (operación de Ross), en pacientes adultos y pediátricos. Estudio preliminar.

INTRODUCTION AND OBJECTIVES: Aortic valve replacement with the patients own pulmonary autograft (the Ross procedure) is by now, the best surgical method for the replacement of the diseased aortic valve in certain groups of patients, this is particularly true for young adults and children or neonates with complex left ventricular outflow tract obstructions. The procedure was described by Donald Ross in 1967, and many years have passed. So in view of the accumulated experience the indications have extended to a wide group of patients which include children, neonates and young adults with formal contraindications for anticoagulation. In this publication we present our experience and our preliminary results in a group of fifteen patients which include adult and pediatric. MATERIAL AND METHODS: In six patients the etiology of lesion was congenital and in the remainder nine the valve had an acquired lesion. Two patients had an open heart procedure before this operation both of them to relieve an obstruction to the left ventricular outflow tract. In this group of patients the Ross procedure was carried out inserting the pulmonary autograft in the aortic position as a total root which was always reconstructed with cryopreserved pulmonary homograft, the mean homograft diameter was 26.1 +/- 4 mm (19-35). RESULTS: In all patients a transesophageal echocardiogram was performed in the operating room and postoperative, 1 or 2 months later. Only in one patient a mild aortic regurgitation was detected, no significant transaortic or transpulmonary gradients were detected postoperative. One patient was reoperated for bleeding in the postoperative course, there was no hospital mortality in our group and all the patients had an uneventful postoperative period. In the short term follow-up (41-155 days). All the patients are free of anticoagulant therapy, all them are in New York Heart Association Functional Class I. CONCLUSIONS: The patients presented in this publication which include adult and pediatric, are the first group of patients operated in our country with some excellent preliminary results. We hope that this procedure will become popular and that other surgical groups will adopt it as another surgical tool to replace a diseased aortic valve.

A randomized study comparing deflazacort and prednisone in heart transplant patients.

Prednisone is widely used by most heart transplantation units despite its frequent side effects. Deflazacort, an oral synthetic steroid with fewer side effects, has been successfully used in patients after heart transplantation, but a prospective study comparing deflazacort and prednisone in transplant patients is lacking. We have carried out, in the last year, a prospective trial of deflazacort versus prednisone involving 35 consecutive heart transplant patients. Two of these patients died perioperatively (surgical mortality, 5.7%), and another two were excluded from the protocol because of diabetes mellitus in one patient and active infection before transplantation in the other patient. Thus 31 patients were enrolled in the 3-month study. All of them were treated with antithymocyte globulin, 10 mg/kg/day for 3 days after transplantation, azathioprine, and cyclosporine; patients were randomly assigned groups: 15 patients to receive deflazacort therapy, 1.5 mg/kg/day, and 16 patients to receive prednisone therapy, 1 mg/kg/day, starting the first day after transplantation. Steroids were rapidly tapered, reaching the maintenance dose at 2 to 3 weeks after transplantation (prednisone, 0.15 mg/kg/day; deflazacort, 0.25 mg/kg/day). Both groups were similar in terms of age, gender, ABO identity, serum cyclosporine levels, azathioprine dosage, and pretransplantation serum glucose and lipids levels. Seven endomyocardial biopsies were performed on each patient, at 1, 2, 3, 5, 7, 10, and 13 weeks after transplantation. Incidence of acute rejection was similar between prednisone and deflazacort groups; 33% of patients receiving prednisone therapy and 42% of patients receiving deflazacort therapy had one episode of 3A or higher rejection (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)