Replacement of the aortic valve or root with a pulmonary autograft in children (original) (raw)
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Extended aortic root replacement with aortic allografts or pulmonary autografts in children
The Journal of Thoracic and Cardiovascular Surgery, 1999
gical therapy, which may include enlargement of the aortic root in addition to replacement of the aortic valve. The therapeutic option of enlargement of the LVOT with insertion of a mechanical or bioprosthetic valve remains limited in children. The need for life-long C omplex left ventricular outflow tract (LVOT) obstruction in children poses a challenge to the cardiac surgeon. LVOT obstruction is frequently characterized by a combination of subvalvular and valvular stenosis. Both elements of obstruction may require sur-Objectives: To evaluate the early results and effectiveness of left ventricular outflow tract enlargement with aortic allograft or pulmonary autograft in children with complex left ventricular outflow tract obstruction. Method: The records of 30 children who underwent aortic root enlargement and replacement with either an aortic allograft (22 patients) or pulmonary autograft (8 patients) between January 1987 and June 1997 were reviewed. The predominant diagnosis was complex left ventricular outflow tract obstruction (n = 19), associated with aortic incompetence in 11 children. Before root enlargement, 27 children underwent surgical valvotomy (14 patients), balloon dilatation (10 patients), or both interventions (3 patients). Mean age at root enlargement was 5.4 ± 3.5 years (range, 2 days-16 years). Most of the children (27 patients) underwent a Konno aortoventriculoplasty. Concomitant septal myectomy was performed in 4 children, mitral valve procedure in 5 children, and endocardial fibroelastosis resection in 1 child. Results: Five children (17%) died in hospital. Four of these were infants less than 2 months old. All had acute aortic incompetence as the result of recent intervention necessitating urgent operation. The fifth child, aged 10 years, died of myocardial failure 2 weeks after the operation. During the follow-up period (mean length, 4.1 ± 2.8 years), sudden death occurred in 1 child 3 months after the operation. Follow-up echocardiograms (obtained for 23 of the surviving 24 children within 3 ± 2.3 years) showed a left ventricular outflow tract gradient reduced from a mean of 65 to 11 mm Hg (P = .001); Z value increased from a mean of -0.5 to 4.1 (P < .001), and aortic incompetence was trivial or mild except in 2 children. Conclusion: Urgent aortic root enlargement in decompensating neonates carries higher mortality rates. In older children, the early results of root enlargement and implantation of allograft or autograft are good. (J Thorac Cardiovasc Surg 1999;118:503-9)
International Journal of Cardiology, 1999
A severely dysfunctioning congenitally bicuspid aortic valve may require surgical treatment within the fourth decade of life. Among conventional options, the pulmonary autograft (PA) offers many theoretical advantages particularly for young patients, including potential for growth, hemodynamic performance, no need for anticoagulants and freedom from endocarditis. However the operation is more complex and longer, may interfere with coronary and right ventricular anatomy and function and may expose the patient to the downside of two valves at risk. Aim of this retrospective study was to evaluate the mid-term results achieved with the PA performed in adolescents and young adults with a bicuspid aortic valve. Between July 94 and June 98, 26 patients, 22 males and four females, with a mean age of 24610 years (range, 11 to 38), underwent bicuspid aortic valve replacement with a pulmonary autograft (stenosis 2-8%; insufficiency 13-50%; combined 11-42%). Eight patients (31%) were in NYHA FC I, 17 (65%) in II, and 1 (4%) in III. Mean preoperative ejection fraction was 6767%. Three patients (11.5%) had a past medical history of endocarditis (healed in all) and in two the PA was a re-do procedure. The PA was inserted as a subcoronary implant in one case (4%) and utilized as a root in the remaining 25 (96%). The right ventricular outflow tract was reconstructed with a cryopreserved pulmonary homograft conduit in all cases. Mean cardiopulmonary bypass and aortic crossclamp times were 204650 min (range, 174 to 300) and 157635 min (range, 133 to 193) respectively. No early or late deaths had occurred at a mean follow-up of 22.5 months (range, 5 to 47.5). The first patient in the series (4%) was reexplored for bleeding and needed transfusions. The subsequent routine use medical and surgical strategies resulted in no further need for postoperative reexploration, and successful containment of total postoperative blood loss (,350 ml / m2BSA). 2-D Echo evaluation of neo-aortic valve competence at 6 months, revealed no evidence of aortic valve regurgitation in 17 (65%), trivial regurgitation in seven (27%), mild in one (4%) and mild-to-moderate in one (4%). The latter patient (subcoronary implant PA) required reoperation. At six months, the mean degree of regression of left ventricular mass compared to pre-operative data, was 36% (333694 to 212660 gr, p,0.05). All patients are asymptomatic, in NYHA FC I, and enjoy normal social interaction. In conclusion, PA root implantation can be offered as a low-risk alternative to conventional prosthetic aortic valve replacement to adolescents and young adults with a bicuspid aortic valve. The routine achievement of blood loss containment has minimized the risk of transfusion thus contributing to expand the indication in young patients. Continued patients evaluation particularly with regard to evidence of neo-aortic valve degeneration, root dilatation and homograft dysfunction in the long term is warranted.
Pediatric Autograft Aortic Root Replacement: A Prospective Follow-Up Study
The Annals of Thoracic Surgery, 2005
Background. The autograft procedure offers children who require aortic valve replacement the advantage of an autologous valve that has growth potential and does not require anticoagulation. However, the autograft procedure is a double valve operation and its durability depends on the lifetime of both the autograft and the pulmonary valve substitute. We present our clinical experience with pediatric autograft aortic root replacement.
Comparison of autograft and allograft aortic valve replacement in children
Journal of Thoracic and Cardiovascular Surgery, 2003
This study was undertaken to compare the clinical and hemodynamic results following aortic valve replacement with a pulmonary valve autograft (Ross procedure) or an allograft valve in children.The records of 107 pediatric aortic valve replacements from 1994 through 2001 were reviewed, including 78 autografts and 25 allografts. Four mechanical aortic valve replacements performed during this period were excluded from analysis.There were 3 perioperative deaths and 1 late death. Reoperations were required in 5 autograft recipients (with autograft preservation in 4) and in 3 allograft recipients (all requiring valve re-replacement). Seven-year survival (96% in both groups) and reoperation-free survival (88% in the autograft group; 73% in the allograft group, P = .5) were not significantly different. Serial echocardiographic studies showed that in the autograft group, left ventricular outflow tract maximal velocity (2.0-1.8 m/s, P = .02) and left ventricular thickness (10.1-8.4 mm, P < .0001) fell significantly. In the allograft group, maximal velocity (2.3-3.0 m/s, P = .03) increased significantly and left ventricular thickness (9.5-9.0 mm, P = .2) showed minimal change. Analysis according to preoperative physiology (aortic stenosis versus insufficiency), congenital cardiac anatomy, number or type of previous operations, age of patient, and use of balloon valvotomy did not predict outcomes.Aortic valve replacement with either the autograft or allograft provides excellent clinical results in children during an intermediate duration of observation. The Ross procedure achieves a superior hemodynamic result, which may be clinically important with longer follow-up.
European Journal of Cardio-Thoracic Surgery, 2008
Objective: The performance of the Ross procedure in the case of geometric mismatch between pulmonary autograft and a bicuspid aortic root has not yet been fully evaluated. To prevent geometrically caused autograft dysfunction, a modification of the surgical technique is necessary. , 50 patients (33 male, 17 female; mean age 50 AE 14 years; range 13-63 years) underwent replacement of a diseased bicuspid aortic valve (stenosis in 14 cases; insufficiency in 21; combined disease in 15) with a Ross procedure. The pulmonary autograft was inserted partially in supra-annular position to correct the geometric mismatch between the deeper base of the noncoronary sinus and the right/left coronary sinus. In 24 of these patients, additional tailoring of the non-coronary sinus was necessary. In eight patients the non-coronary sinus was covered with a glutaraldehyde treated autologous pericardial patch to prevent pseudoaneurysm formation. Patients were followed up 1, 2, 5 and 10 years postoperatively. Results: There were no early or late deaths. There were six reoperations. One patient was reoperated because of persistent severe aortic valve insufficiency 9 months postoperatively. Three patients were reoperated for formation of subannular pseudoaneurysm, 6, 9 and 30 months postoperatively. One patient was reoperated for closure of a paravalvular dehiscence. Another patient was reoperated 1 year postoperatively because of a severe pulmonary stenosis due to excessive calcification of the bioprosthesis. Echocardiographic follow-up of the remaining patients showed no evidence of residual or recurrent pulmonary autograft regurgitation or progression of aortic root dilatation. Conclusion: Autograft replacement of the bicuspid aortic valve is challenging, as the geometric mismatch has to be adjusted. Valve dysfunction is avoided by a supra-annular implantation technique, but pseudoaneurysm formation at the base of the non-coronary sinus is a worrying aspect. Patch reinforcement may solve this issue. #
The Journal of Thoracic and Cardiovascular Surgery, 2002
Objectives: This report reviews our experience with repeated aortic root replacement after failure of cryopreserved aortic allografts placed during childhood and compares replacement with aortic allografts, pulmonary autografts, and mechanical valved conduits in these patients. Methods: This was a retrospective analysis of all such patients from 1986 through May 2001. Results: There were 25 operations (11 aortic allografts, 9 pulmonary autografts, and 5 mechanical valved conduits) among 23 patients. The mean time to reoperation was 6.3 years. There were 2 in-hospital deaths (8%, 1 patient with a pulmonary autograft and 1 with a mechanical valved conduit). There were 2 early nonfatal valve-related events (1 patient with an aortic allograft and 1 with a pulmonary autograft). There were no late valve-related deaths and 2 late non-valve-related deaths of patients with aortic allografts placed. No variable predicted early death or early valve-related event. No differences in preoperative characteristics, hospital variables, early outcomes, or late outcomes were detected among the groups. Overall, 19 patients are alive (18 in New York Heart Association functional class I and 1 in New York Heart Association functional class III) at a mean follow-up of 49 months. Two late aortic allograft failures necessitated reoperation. All patients with successful pulmonary autografts had excellent autograft function at a mean follow-up of 68 months. All early survivors with mechanical valved conduits are alive and free of valve-related events (mean follow-up 71 months). Five-year freedoms from valve-related death or event (Kaplan-Meier) were 84% for all patients, 91% for aortic allografts, 78% for pulmonary autografts, and 80% for mechanical valved conduits (no statistically significant group differences by log-rank test). Conclusions: Replacement of cryopreserved aortic root allografts placed during childhood is safe. Five-year pulmonary autograft durability is excellent, although the risk of early failure may be increased. Differences in 5-year conduit longevity were not detectable. T he management of aortic valve disease in children is challenging. Multilevel left ventricular outflow tract (LVOT) pathology, additional congenital heart lesions, smaller patient size with growth requirements, and difficulties with anticoagulation add increased complexity in treating children relative to treating adults. In 1987 Clarke and associates 1 introduced extended aortic root replacement with cryopreserved aortic allografts for the treatment of complex LVOT obstruction in children (Figure 1). 2 This procedure combines the concept of aortoventriculoplasty previously described by Konno and colleagues 3 and Rastan and Koncz 4 that featured total allograft aortic root replacement with direct coronary reimplantation, From the Division of Cardiothoracic Surgery a and the