Jaime Casares

Reemplazamiento valvular aórtico con autoinjerto pulmonar ( operación de Ross) , en pacientes adultos y pediátricos. Estudio preliminar

Introduccion y objetivos. El reemplazamiento valvular aortico con autoinjerto pulmonar (opera-cion de Ross) se ha llegado a establecer como uno de los mejores metodos quirurgicos para el reemplazamiento de la valvula aortica en determinados grupos de pacientes. Aunque fue descrita por Ross en 1967, han tenido que pasar muchos anos para que, a la vista de la experiencia acumulada, las indicaciones se hayan extendido, incluso, a pacientes recien nacidos y pediatricos con formas complejas del tracto de salida de ventriculo izquierdo. El objetivo de nuestro trabajo es aportar la experiencia y resultados preliminares en un grupo de quince pacientes (adultos y pediatricos), intervenidos con esa tecnica. Material y metodos. En 6 pacientes la etiologia fue congenita y en 9 adquirida. Dos de ellos inter-venidos previamente con circulacion extracorporea, por obstruccion severa del tracto de salida de ventriculo izquierdo. Resultados. En todos ellos, se realizo procedimiento de Ross con insercion del autoinjerto pulmonar en forma de raiz total en posicion aortica, con reimplantacion de coronaria. La media de dia-metro de los homoinjertos pulmonares criopreservados fue de 26,1 ± 4 mm (19-35). En todos los casos se hizo estudio ecocardiografico transesofagico intraoperatorio y postoperatorio (1-2 meses). Solo un caso presento insuficiencia leve del autoinjerto pulmonar y ningun caso tuvo gradiente transaortico o transpulmonar postoperatorio. Un paciente fue reintervenido por hemorragia precozmente, ningun paciente presento complicaciones significativas y no hubo ningun caso de mortalidad hospitalaria, ni en el seguimiento a corto plazo (41-155 dias). Todos los pacientes estan libres de tratamiento anticoagulante en grado funcional I de la New York Heart Association. Conclusiones. En los resultados ecocardiograficos preliminares a corto plazo de nuestra serie, que incluye pacientes adultos y pediatricos, se observa un excelente comportamiento hemodinamico del autoinjerto pulmonar.

Resultados a corto plazo en la técnica de Ross. ¿Influye la etiología de la valvulopatía aórtica?

Rev Esp Cardiol 2004;57(6):531-7 531 Introducción. La técnica de Ross se ha establecido como un método de sustitución valvular aórtica apropiado en pacientes pediátricos y adultos jóvenes. Existe controversia sobre los resultados de esta técnica según la valvulopatía aórtica sea congénita o adquirida. El objetivo de este estudio es analizar los resultados de esta técnica en las diferentes etiologías. Pacientes y método. Analizamos a 61 pacientes intervenidos con técnica de Ross desde noviembre de 1997 a noviembre de 2001, con edades comprendidas entre los 6 y los 54 años; de ellos 44 (72%) eran varones. El tiempo medio de seguimiento fue de 15,6 ± 10,6 meses. La lesión valvular fue: estenosis en 17 pacientes, insuficiencia en 22 y doble lesión en 22. Se separó a los pacientes en dos grupos: grupo I, etiología congénita (40 pacientes), y grupo II, etiología adquirida (21 pacientes: en 14, etiología reumática; en 2, degenerativa, en 2, endocarditis, y en 3, otras). Resultados. Los datos preintervención mostraron diferencias significativas en la edad, el grado funcional y el porcentaje de pacientes con cirugía cardíaca previa. En el seguimiento último, los gradientes del autoinjerto y del homoinjerto fueron similares en ambos grupos, sin significación estadística. Los diámetros diastólico y sistólico medios y la fracción de eyección fueron normales en ambos grupos, sin diferencias. Los eventos mayores al seguimiento fueron, en el grupo I: 1 paciente fallecido, 1 caso de endocarditis del autoinjerto y 2 casos de implantación de stent en el homoinjerto; en el grupo II: 2 reintervenciones por disfunción grave del autoinjerto, sin diferencias estadísticamente significativas. Conclusión. La técnica de Ross presenta baja morbimortalidad a corto plazo, independientemente de la etiología.

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

Para analizar la incidencia y los factores predictores de la insuficiencia del autoinjerto aortico durante el seguimiento tras la intervencion de Ross, de 102 pacientes operados consecutivamente en nuestro centro entre 1997 y 2009, se selecciono a 83 (media de edad, 32 ± 11 anos) sin regurgitacion significativa del autoinjerto al alta y con al menos un ecocardiograma de seguimiento. La insuficiencia del autoinjerto se definio como aquella al menos moderada por ecocardiografia. Tras una mediana (intervalo) de 4,2 (0,2-10,9) anos de seguimiento, 8 (9,6%) pacientes presentaron esta complicacion (3 precisaron sustitucion valvular). La probabilidad de supervivencia libre de insuficiencia del autoinjerto fue del 90% (intervalo de confianza [IC] del 95%, 83%-98%) a los 5 anos. En el analisis multivariable, la intervencion 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 tamano 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 complicacion.

Lecompte Procedure in a Case of Anatomically Corrected L-Malposition of the Great Arteries

We present the case of a 12-month-old patient, echocardiographically diagnosed with tetralogy of Fallot, with indications for surgical treatment due to cyanosis. In the hemodynamic study, subaortic interventricular communication (IVC) was found as well as aortic override, infundibular, valvular, and supravalvular pulmonary stenosis, together with L-malposition of the great arteries and the right coronary artery that crosses the pulmonary infundibulum very close to the valvular plane (Figure). Interventricular communication was closed using a polytetrafluoroethylene (PTFE) patch via the atrial route, the pulmonary artery was sectioned and directly reimplanted onto the right ventricle, with infundibular resection and enlargement of the anterior wall of the pulmonary outflow tract using an autologous pericardial patch without prosthetic conduit (Lecompte procedure or REV1). A Lecompte maneuver was not necessary. After correction, the RV/LV pressure ratio was 0.4, without residual pulmonary gradient. There were no complications at 12-month follow-up. The anatomically corrected malposition of great arteries is an infrequent type of conotruncal malformation where there is ventriculoarterial concordance despite presenting great vessel malposition. Thus, if there is atrioventricular concordance, the circulatory physiology is normal and surgical treatment consists in correcting the associated lesions, usually interventricular communication with infundibular pulmonary stenosis. It can also be associated with tricuspid hypoplasia/atresia with right ventricular hypoplasia, right aortic arch, juxtaposition of atrial appendages and dextrocardia.2 In this malformation, the correction of the pulmonary stenosis is determined by the position of the right coronary artery in the right ventricular infundibulum, which usually entails using an extracardiac conduit. This involves successive reinterventions in order to replace this conduit. Morita et al3 describe a transannular enlargement technique via patch plasty of the right atrioventricular groove, applicable in patients where the coronary artery is displaced away from this. In our case, given the age of the patient and the position of the coronary arteries, we chose the Lecompte procedure, connecting the pulmonary artery directly to a right ventriculotomy. This technique preserves the growthpotential of RV-pulmonary artery continuity and avoids the reinterventions due to the extracardiac conduit, making it especially attractive for use in young children. Recent studies comparing both procedures demonstrate significantly greater late morbidity with the conventional technique, which is associated with reintervention due to conduit obstruction.4,5 In the Lecompte procedure, most reinterventions due to pulmonary restenosis are associated with the use of patches with a pericardial monocusp valve which calcifies and induces obstruction.6,7 The use of a patch without a monocusp valve, as in our case, bypasses this problem, but it produces a pulmonary regurgitation that can cause late right ventricular dysfunction. In the anatomically corrected L-malposition of great vessels with pulmonary stenosis, the Lecompte procedure offers an excellent alternative to RV-pulmonary artery conduit, since it enables earlier correction and reduces the need for reinterventions.

Short-Term Results With the Ross Procedure. Does the Etiology of Aortic Valvulopathy Affect the Outcome?

INTRODUCTION The Ross procedure has become established as an appropriate method for aortic valve replacement in children and young adults. There is controversy regarding the results of this surgical technique depending on whether the aortic valve disorder is congenital or acquired. The objective of this study was to analyze the outcome of this technique in different etiologies. PATIENTS AND METHOD We analyzed 61 patients who underwent the Ross procedure between November 1997 and November 2001. Age range was 6 to 54 years, and 44 patients (72%) were male. The mean duration of follow-up was 15.6 (10.6) months. The aortic valve lesion was stenosis in 17 patients, regurgitation in 22 and both in 22. The patients were divided into two groups: etiology was congenital in group I (40 patients) and acquired in group II (21 patients: 14 rheumatic, 2 degenerative, 2 endocarditis and 3 other). RESULTS Pre-intervention data showed significant differences in age, functional class and percentage of patients with previous cardiac surgery. In the last follow-up examination, autograft gradient and homograft gradient were similar in both groups. Diastolic and systolic diameters and left ventricle ejection fraction were normal in both groups and did not differ between groups. Major events during follow-up were: 1 patient died, 1 patient had endocarditis, and 2 patients needed stent implantation in the homograft in group I; 2 patients in group II underwent reoperation because of severe autograft dysfunction. There were no statistically significant differences between groups. CONCLUSION Short-term morbidity and mortality associated with the Ross procedure are low in patients with either congenital or acquired aortic valvulopathy.