Right ventricular function after pulmonary autograft replacement of the aortic valve.

BACKGROUND: The pulmonary autograft operation (the Ross procedure) involves excision of a portion of the right ventricular (RV) outflow tract, prolonged cross-clamp times, and insertion of a pulmonary homograft. There is concern about the effect of such operations on right ventricular function. METHODS AND RESULTS: Twenty-five patients undergoing either pulmonary autograft or homograft replacement of the aortic valve as part of a prospective randomized trial had echocardiographic RV long-axis measurements performed before surgery and 6 months (range 3 to 12 months) after surgery. In all patients, systolic excursion (SE) and both shortening and lengthening rates (SR and LR, respectively) were reduced postoperatively (P<0.05) (homografts: SE 1.5+/-0.4 versus 2.3+/-0.6 cm, SR 6.8+/-2.1 versus 9. 6+/-3.1 cm/s, LR 6.0+/-1.8 versus 8.9+/-3.0 cm/s; autografts: SE 1. 4+/-0.4 versus 2.2+/-0.4 cm, SR 5.8+/-3.0 versus 8.2+/-3.0 cm/s, LR 5.7+/-1.9 versus 8.5+/-3.7 cm/s). There were no differences between the 2 groups. Eighteen patients who had undergone either aortic homograft or pulmonary autograft surgery were studied between 6 and 35 months after surgery. RV volumes were assessed with the use of MRI in addition to echocardiographic RV long-axis measurements. Global volumes were increased to a similar amount in both groups (homografts: end-diastolic volume 145+/-34 mL, end-systolic volume 78+/-23 mL; autografts: end-diastolic volume 157+/-33 mL, end-systolic volume 89+/-25 mL; P=NS), whereas stroke volumes were maintained in both groups (homografts 67+/-15 mL, autografts 67+/-16 mL; P=NS). RV SE was depressed in both groups to a similar degree to that seen with the previous group (homografts 1.5+/-0.3 cm, autografts 1.4+/-0.2 cm). CONCLUSIONS: Aortic valve replacement with either a pulmonary autograft or an aortic homograft leads to a degree of persistent RV longitudinal dysfunction that is not more pronounced in those undergoing the Ross procedure. The mechanisms and long-term effects of these changes must be further studied.

Pulmonary autograft versus aortic homograft for rereplacement of the aortic valve: results from a subset of a prospective randomized trial.

BACKGROUND: The use of a pulmonary autograft for rereplacement of the aortic valve has both potential advantages and disadvantages. This study details the early results of a subset of patients enrolled in a prospective randomized trial comparing pulmonary autografts and aortic homografts who have had previous aortic valve replacements. METHODS AND RESULTS: A total of 47 patients who had undergone >/=1 previous aortic valve replacement were randomized to receive either a pulmonary autograft (24 patients aged 40+/-11 years) or an aortic homograft (23 patients aged 37+/-11 years) for rereplacement of the aortic valve. One early death occurred in the homograft group, and 1 late (7 months) death occurred in the autograft group. One patient who received a pulmonary autograft was reoperated on for inflammatory pulmonary stenosis. One patient in each group was reopened for bleeding (both within 24 hours). Two patients in the autograft group had postoperative neurological weakness; they fully recovered over 2 months. Hospital stay, blood loss, incidence of perioperative arrhythmia, and markers of coronary ischemia were similar between the 2 groups. At 6-month follow-up (range, 1 to 12 months), left ventricular end-diastolic diameter was similar in both groups (homografts, 5.0+/-0.9 cm; autografts, 5.2+/-0.6 cm; P=NS), and no patient in either group had significant aortic valve dysfunction. CONCLUSIONS: Rereplacement of the aortic valve with a pulmonary autograft is feasible and safe in patients aged 14 to 60, regardless of their preoperative diagnosis or clinical condition.