Pulmonary homograft stenosis in the Ross procedure: Incidence, clinical impact and predictors in long-term follow-up.

BACKGROUND: The Ross procedure is used in the treatment of selected patients with aortic valve disease. Pulmonary graft stenosis can appear in the long-term follow-up after the Ross intervention, but the factors involved and its clinical implications are not fully known. AIM: To describe the incidence, clinical impact and predictors of homograft stenosis and reintervention after the Ross procedure in a prospective series in a tertiary referral hospital. METHODS: From 1997 to 2009, 107 patients underwent the Ross procedure (mean age: 30±11 years; 69% men; 21 aged<18 years), and were followed for echocardiographic homograft stenosis (peak gradient>36mmHg) and surgical or percutaneous homograft reintervention. RESULTS: After 15 years of follow-up (median: 11 years), echocardiographic and clinical data were available in 91 (85%) and 104 (98%) patients, respectively: 26/91 (29%) patients developed homograft stenosis; 10/104 (10%) patients underwent 13 homograft reintervention procedures (three patients underwent surgical replacement, three received a percutaneous pulmonary valve and one needed stent implantation). The other three patients underwent two consecutive procedures in follow-up; one died because of a procedure-related myocardial infarction. Rates of survival free from homograft stenosis and reintervention at 1, 5 and 10 years were 96%, 82% and 75% and 99%, 94% and 91%, respectively. Paediatric patients had worse survival free from homograft stenosis (hazard ratio [HR] 3.50, 95% confidence interval [CI]: 1.56-7.90; P=0.002), although there were no significant differences regarding reintervention (HR: 2.01, 95% CI: 0.52-7.78; P=0.31). Younger age of homograft donor was also a stenosis predictor (HR: 0.97, 95% CI: 0.94-0.99; P=0.046). CONCLUSIONS: The probabilities of homograft stenosis and reintervention 10 years after the Ross procedure were 29% and 10%, respectively; only one patient had a reintervention-related death. Younger donor and recipient age were associated with a higher rate of stenosis.

Autograft failure during follow-up after the Ross procedure: predictive factors in a prospective series.

To determine the incidence of, and predictive factors for, aortic autograft failure during follow-up after the Ross procedure. Of 102 consecutive patients who underwent surgery at our centre between 1997 and 2009, we selected 83 (age 32+/-11 years), all of whom had been discharged without significant autograft regurgitation and for whom at least one follow-up echocardiogram was available. Autograft failure was defined as the presence of at least moderate regurgitation on echocardiography. After a median follow-up period of 4.2 years (range 0.2-10.9 years), eight patients (9.6%) developed this complication, three of whom required valve replacement. The probability of survival without autograft failure at 5 years was 90% (95% confidence interval [CI] 83%-98%). Multivariate analysis showed that undergoing surgery during the first 6 months of the learning curve (hazard ratio = 9.1; 95% CI, 1.4-59.4; P=.021) and a large pulmonary annulus size, normalized by body surface area, (hazard ratio = 1.4; 95% CI, 1.016-1.924; P=.04) were independent predictors of this complication.

Insuficiencia del autoinjerto durante el seguimiento tras la intervención de Ross: factores predictores en una serie prospectiva / Autograft failure during follow-up after the ross procedure: predictive factors in a prospective series

Para analizar la incidencia y los factores predictores de la insuficiencia del autoinjerto aórtico durante el seguimiento tras la intervención de Ross, de 102 pacientes operados consecutivamente en nuestro centro entre 1997 y 2009, se seleccionó a 83 (media de edad, 32 ± 11 años) sin regurgitación significativa del autoinjerto al alta y con al menos un ecocardiograma de seguimiento. La insuficiencia del autoinjerto se definió como aquella al menos moderada por ecocardiografía. Tras una mediana (intervalo) de 4,2 (0,2-10,9) años de seguimiento, 8 (9,6%) pacientes presentaron esta complicación (3 precisaron sustitución valvular). La probabilidad de supervivencia libre de insuficiencia del autoinjerto fue del 90% (intervalo de confianza [IC] del 95%, 83%-98%) a los 5 años. En el análisis multivariable, la intervención en los primeros 6 meses de la curva de aprendizaje (hazard ratio [HR] = 9,1; IC del 95%, 1,4-59,4; p = 0,021) y el mayor tamaño del anillo pulmonar (normalizado para la superficie corporal, HR = 1,4; IC del 95%, 1,016-1,924; p = 0,04) fueron predictores independientes de esta complicación (AU)

To determine the incidence of, and predictive factors for, aortic autograft failure during follow-up after the Ross procedure. Of 102 consecutive patients who underwent surgery at our centre between 1997 and 2009, we selected 83 (age 32±11 years), all of whom had been discharged without significant autograft regurgitation and for whom at least one follow-up echocardiogram was available. Autograft failure was defined as the presence of at least moderate regurgitation on echocardiography. After a median follow-up period of 4.2 years (range 0.2-10.9 years), eight patients (9.6%) developed this complication, three of whom required valve replacement. The probability of survival without autograft failure at 5 years was 90% (95% confidence interval [CI] 83%-98%). Multivariate analysis showed that undergoing surgery during the first 6 months of the learning curve (hazard ratio = 9.1; 95% CI, 1.4-59.4; P=.021) and a large pulmonary annulus size, normalized by body surface area, (hazard ratio = 1.4; 95% CI, 1.016-1.924; P=.04) were independent predictors of this complication (AU)

Bronchial artery aneurysm treated with aortic stent graft and fibrin sealant.

Bronchial artery aneurysm occurs rarely but can cause a life-threatening hemorrhage when it ruptures. The traditional therapy has been aneurysm resection or transcatheter arterial embolization. We report a case of mediastinal bronchial artery aneurysm which could not be occluded with transcatheter arterial embolization and instead was treated with a thoracic aortic stent graft and embolization with fibrin sealant.

Prospective evaluation of aortic valve replacement in young adults and middle-aged patients: mechanical prosthesis versus pulmonary autograft.

BACKGROUND AND AIM OF THE STUDY: The best option for aortic valve replacement (AVR) in young adults and middle-aged patients remains controversial. A longitudinal comparison between the Ross procedure (RP) and mechanical prosthesis (MP) was conducted in this group of patients. METHODS: Between January 1997 and January 2003, 125 consecutive patients (age range: 20-50 years) were submitted for AVR; 62 patients (mean age 37.73+/-7.28 years) were included in the MP group, and 63 (mean age 35.33+/-7.63 years) in the RP group. Gender, etiology, NYHA functional class and other preoperative data were comparable between the two groups. RESULTS: The operative mortality was four (6.5%) in the MP group, and one (1.6%) in the RP group (p = NS). The postoperative complication rate was similar in both groups. Two RO patients required early autograft replacement due to severe regurgitation. There were no late deaths during the follow up period. In the MP group, three patients (4.8%) suffered major bleeding, three (4.8%) were diagnosed with prosthetic endocarditis (one required reoperation), and three (4.8%) suffered valve- or coumarin-related thromboembolic complications. All RP patients were free from bleeding, thromboembolic, or infectious complications, but three suffered severe pulmonary homograft stenosis (one re-replacement, one Palmaz stent, and one under clinical surveillance). The combined freedom from death or major complications was 64.72+/-4.3% in the MP group, and 87.92+/-9.65% in the RP group (p = 0.068). CONCLUSION: Intraoperative and early postoperative morbidity and mortality rates were similar among RP and MP patients, despite a steep learning curve during the early RP cases. Although the follow up was limited, and homograft-related morbidity was seen in the RP group, the overall five-year major complication rate supported use of the pulmonary autograft for AVR in patients aged between 20 and 50 years.

The Ross procedure.

BACKGROUND: The search for the ideal substitute for the aortic valve led Donald Ross to develop the pulmonary autograft concept in 1967. A historical, technical, and scientific review of this surgical option is presented together with our clinical experience. MATERIALS AND METHODS: The literature is reviewed to identify the advantages and pitfalls of the Ross procedure over the last decades. We also present our clinical experience with 92 patients operated between 1997 and May 2003. RESULTS: Of the total, 70.65% (n = 65) were males, mean age was 29.32 +/- 11.9 years, with 20 patients under 16 and 6 patients under 10 years. Twenty-five patients (27.17%) had 31 previous interventions. There were 41 associated procedures in 34 patients. Perioperative mortality was 2.17% (two patients). Eight patients required reexploration for bleeding, one required an aortocoronary bypass, and one a permanent pacemaker. Follow-up was 97% with 2.71 patients/year (average 32.55 +/- 19.01 months). Two patients required autograft replacement, one suffered a 44-mm dilatation of the autograft, and one 13-year-old girl developed autograft endocarditis. Six patients suffered severe homograft stenosis (>50 mmHg), two were treated percutaneously, and one required replacement. Combined freedom from reintervention is 93.56 +/- 2.81% at 5 years. CONCLUSIONS: The Ross procedure is a mature concept with thousands of patients operated worldwide and a cumulative experience of over 30 years. Although we believe that it is the procedure of choice in the pediatric population, women in child-bearing age, and substantial subgroups of adult patients, efforts must continue to minimize the incidence of auto- and homograft failure in the long term.

Mitral homograft in the tricuspid position, aortic homograft and mitral plasty in a drug addict with multiple valve endocarditis.

The case is reported of multiple valve surgery using as little prosthetic material as possible in a drug addict with recurrent right and left bacterial endocarditis. The patient underwent aortic valve replacement with a cryopreserved aortic homograft, mitral repair and tricuspid valve replacement with a mitral homograft, using a modified technique. The indications and surgical options for tricuspid valve endocarditis in this patient group are discussed, with particular focus on technical aspects of using mitral homografts in the tricuspid position.

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

La sustitución valvular aórtica con autoinjerto pulmonar fue descrito por Donald Ross en 1967, aunque no fue ampliamente aceptado por cardiológos y cirujanos cardíacos, fundamentalmente por tratarse de un procedimiento quirúrgico complejo y poner en riesgo dos válvulas cardíacas. En los últimos 10-15 años, los resultados publicados de numerosas series demuestran que se trata de uno de los mejores métodos de reemplazamiento de la válvula aórtica, muy especialmente en pacientes pediátricos y adultos jóvenes.En el presente trabajo, revisamos las indicaciones y contraindicaciones actuales, así como nuestra experiencia clínica con 26 pacientes (adultos y pediátricos) y el análisis de los primeros 22, con un seguimiento mínimo de 6 meses (180-620 días). El seguimiento fue completo (100%). Cinco pacientes eran menores de 14 años. La edad media del grupo fue de 31,4 ± 12,6 años. En 3 pacientes (11%) se había realizado un procedimiento percutáneo previo y otros 4 pacientes (14%) habían sido intervenidos quirúrgicamente. No ha habido ningún caso de mortalidad precoz ni tardía.En el último seguimiento, 19 de estos 22 pacientes (86,36%) no tenían insuficiencia (>= grado 1) del autoinjerto y en un caso ésta era moderada (grado 2). Los 2 pacientes restantes desarrollaron una insuficiencia severa (grado 4) y hubieron de ser reintervenidos, evolucionando de forma satisfactoria. El gradiente pico medio era de 7,85 ± 5 mmHg (3-29) a los 18 meses. Los pacientes con estenosis aórtica preoperatoria mostraron una reducción significativa del índice de masa miocárdica (208,7 ± 32 a 95,8 ± 28,8 g/m2). En estos pacientes, el grosor del septo y de la pared posterior se redujo significativamente, ya en el primer mes.Dos pacientes pediátricos desarrollaron un gradiente transpulmonar > 50 mmHg, implantándose un stent intravascular en uno de ellos. No se ha observado insuficiencia significativa del homoinjerto en ningún caso.Todos los pacientes continúan asintomáticos (grado funcional I) sin medicación. No se ha observado ningún episodio tromboembólico o hemorrágico ni ningún caso de endocarditis. Ningún paciente recibe tratamiento anticoagulante.El seguimiento clínico y ecocardiográfico a medio plazo de nuestra serie demuestra un buen comportamiento, tanto del autoinjerto pulmonar como del homoinjerto, tras el procedimiento de Ross (AU)

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 innmumerous 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 significanthy, 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 serie, are excellent after the Ross procedure (AU)