Marise Brenner Affonso da Costa

Dez anos de experiência com a operação de Ross

OBJECTIVE To evaluate the 10-year outcomes of the Ross Operation, analyzing survival rate, incidence of reoperations, and late performance of pulmonary autografts and homografts in the reconstruction of the right ventricular outflow tract. METHODS Two hundred and twenty seven patients with a mean age of 29.1 +/- 11 years underwent Ross operation from May 1995 to February 2005. The most prevalent etiology was rheumatic disease in 61% of the cases. Autografts were implanted using the total root replacement technique in 202 cases, with intraluminal cylinder in 20, and in the subcoronary position in 5. The right ventricular outflow tract was conventionally reconstructed with cryopreserved homografts (n = 160), with proximal extension of the homograft with pericardium (n = 41), and with decellularized homografts (n = 26). The postoperative follow-up ranged from 1 to 118 months (mean = 45.5 months). RESULTS Hospital mortality was 3.5%, and long-term survival was 96.9% at ten years. No episodes of thromboembolism and only two cases of endocarditis occurred. Eleven patients underwent reoperation because of problems related to the auto and/or homograft, progression of rheumatic mitral valve disease, and iatrogenic coronary insufficiency. After 10 years, 96.4% and 96.2% of the patients were free from reoperation in the autograft and homograft groups, respectively. No late autograft dilatation was observed. Reconstruction of the left ventricular outflow tract with decellularized homografts significantly reduced the incidence of gradients on late follow-up. CONCLUSION Late outcomes with the Ross Operation were associated with an excellent long-term survival and a low incidence of reoperations and late morbidity. We consider this procedure the best option for the surgical treatment of aortic valve disease in children and young adults.

Análise das atividades dos oito anos iniciais do Banco de Valvas Cardíacas Humanas do Hospital de Caridade da Irmandade da Santa Casa de Misericórdia de Curitiba

OBJECTIVE: The aim of this study was to retrospectively evaluate the first eight years of activities of the Human Heart Valve Bank of Hospital de Caridade da Irmandade da Santa Casa de Curitiba (BVCHSC), analysing aspects related to procurement, processing, storage and distribution of homologous cardiovascular grafts. METHOD: Initial donor screening was achieved according the national guidelines for human organ procurement, besides specific BVCHSC criteria. Hearts were obtained from multiple organ donors, non-beating heart donors and heart transplant recipients, with total ischemic times under 48 hours. Donor ages varied from neonates up to 60 years for aortic valves and 65 years for pulmonary valves. The dissected grafts had their dimensions measured and their morphology evaluated, using a classification system with category 0 (discarded), 1 (minimal morphological alterations) and 2 (perfect). The incidence and microorganisms responsible for organ contamination were determined, as was the efficiency of the decontamination solution. Aspects related to graft distribution were also analysed. RESULTS: From September 1996 to February 2005, 1059 hearts from 19 Brazilian states were recevied at BVCHSC. From these, 977 (92.3%) were from brain-death donors. A total of 2105 grafts were processed and of the aortic and pulmonary grafts that were analysed, 783 were in category 2, 697 in category 1 and 186 were discarded due to morphological abnormalities. In total, 433 received grafts were contamined and the sterilization solution was efficient in 330 cases. 571 (27.1%) grafts were rejected during some phase of the processing, mainly due to contamination and morphological abnormalities. A total of 1338 grafts were distributed to 74 health institutions and were more commonly used for aortic valve replament (529), correction of congenital heart diseases (478) and during the Ross procedure (272). CONCLUSIONS: The activities of the BVCHSC during the initial eight years were satisfactory, fulfilling the proposed goals.

20 years experience with the Ross operation in middle-aged patients: the autologous principle is still alive

Objectives Review our long-term results with the Ross operation in middle-aged patients. Methods Between 1995 and 2016, 129 consecutive patients (106 males); mean age (47.2 ± 5.2 years) underwent a Ross operation. Right ventricular outflow tract (RVOT) reconstruction was performed with cryopreserved (n = 45) or decellularized allografts (n = 84). Mean follow-up was 8.4 ± 5.3 years (0.1 20.5 years). We analyzed early and late mortality, as well as valve related events and the need for reoperations. Results Early mortality was 1.6% and late survival was 87.6% at 16 years. There were 4 reoperations on the pulmonary autograft (96% freedom at 16 years) and 2 on the pulmonary allografts (99% freedom at 16 years). The 16-year freedom from more than mild aortic insufficiency (AI) and a late root diameter >45 mm was 64% and 71%, respectively. Patients with the preoperative diagnosis of AI are at greater risk for these complications. Among the allografts, decellularized allografts showed superior freedom from structural valve dysfunction. Conclusions The Ross operation in this cohort was associated with long-term survival similar to the general population and low incidence of reoperations. Patients with the preoperative diagnosis of AI are at increased risk for late autograft insufficiency and root dilatation. Decellularized allografts presented the best results for reconstruction of the RVOT. These results support the conclusion that the Ross operation has an important role in the treatment of middle-aged patients with aortic valve disease, especially those with pure aortic stenosis.

Dez anos de experiência com a substituição da valva aórtica com homoenxertos valvares aórticos implantados pela técnica da substituição total da raiz

OBJETIVO: Avaliar os resultados imediatos e tardios de 10 anos da substituicao da valva aortica por homoenxertos valvares aorticos implantados pela tecnica de substituicao total da raiz, e identificar eventuais fatores de risco correlacionados com a degeneracao tecidual primaria dos enxertos. METODO: Entre maio/1995 e janeiro/2006, 282 pacientes com media de idade de 52,8±16,6 anos foram submetidos a substituicao da valva aortica com homoenxertos valvares. As etiologias prevalentes foram a valva aortica bicuspide calcificada e a degeneracao senil em 49% dos casos. Quarenta e sete pacientes eram reoperacoes e 26 tinham endocardite bacteriana aguda. Procedimentos associados foram realizados em 113 pacientes. O homoenxerto valvar foi implantado pela tecnica de substituicao total da raiz em todos os casos. O tempo de seguimento pos-operatorio variou de 1 a 129 meses (media = 41±25 meses). RESULTADOS: A mortalidade imediata foi de 7%, sendo de apenas 2,6% nos casos de operacao eletiva para a substituicao isolada da valva aortica. Dos 262 que receberam alta hospitalar, foi possivel obter avaliacao clinica e/ou ecocardiograma em 209 deles, sendo 51 (20%) perdidos durante o seguimento. Houve 17 obitos tardios, entre o 2o e 81o meses de pos-operatorio, o que resultou em curva atuarial de sobrevida global de 90% e 80,1% aos 5 e 10 anos de evolucao, respectivamente. Foram observados apenas oito episodios tromboembolicos (quatro imediatos e quatro tardios), durante a evolucao para uma incidencia linearizada de 0,3%/100 pacientes/ano. Endocardite bacteriana ocorreu em tres ocasioes (0,4%/100 pacientes/ano). Nove pacientes foram reoperados, dos quais apenas tres por problemas no homoenxerto (uma degeneracao tecidual e dois casos de endocardite), o que resultou numa probabilidade de 94% livres dessa complicacao aos 10 anos de seguimento. A analise do ecocardiograma tardio demonstrou gradiente maximo variando entre 3 a 47 mmHg (media de 14,5 mmHg), sendo que apenas dois pacientes apresentavam gradiente superior a 40mmHg. Insuficiencia valvar moderada foi encontrada em quatro pacientes. CONCLUSOES: Os resultados imediatos e tardios com a substituicao da valva aortica por homoenxerto valvar criopreservado foram excelentes, com boa capacidade funcional e baixa morbi-mortalidade tardia. O unico fator de risco para a degeneracao tecidual primaria foi a idade do paciente menor que 20 anos. Homoenxertos aorticos representam uma excelente opcao para pacientes com idade acima de 40-50 anos, especialmente naqueles com contra-indicacao ou que nao desejem fazer o uso de anticoagulantes.

Experimental study with deccelularized porcine heterografts: the prosthesis of the future

OBJETIVO: Avaliar, comparativamente, o comportamento de homoenxertos valvares criopreservados e de heteroenxertos descelularizados implantados na via de saida do ventriculo direito de carneiros jovens, assim como relatar a experiencia clinica inicial com homoenxertos descelularizados em pacientes submetidos a operacao de Ross. METODO: No grupo A, foram implantados quatro homoenxertos pulmonares criopreservados e no Grupo B, quatro heteroenxertos porcinos valvares descelularizados com acido deoxicolico. Em cada grupo, dois animais foram sacrificados no 3o mes e dois no 5o mes de pos-operatorio. As pecas foram avaliadas macroscopicamente e por radiografias, alem de exame microscopico com coloracoes HE, Tricromico de Mallory e Sirius Red. A experiencia clinica com quatro pacientes submetidos a operacao de Ross com emprego de homoenxertos valvares descelularizados e relatada. RESULTADOS: Todos os animais sobreviveram. Os ecocardiogramas demonstraram boa funcao valvar nos dois grupos. Embora as cuspides valvares em ambos os grupos tivessem aspecto macroscopico normal, a mensuracao de calcio e o estudo radiologico demonstraram inicio de calcificacao focal nos homoenxertos criopreservados, mas nao nos heteroenxertos descelularizados. Esses achados foram confirmados por exames microscopicos. Os homoenxertos criopreservados demonstraram perda de sua celularidade, enquanto que os heteroenxertos descelularizados demonstraram repopulacao progressiva da matriz colagena com fibroblastos, assim como reendotelizacao. Os quatro pacientes operados tiveram evolucao pos-operatoria imediata satisfatoria, com funcao normal dos homoenxertos. CONCLUSOES: Heteroenxertos valvares descelularizados foram progressivamente repopulados por celulas autogenas e exibiram minima tendencia a calcificacao no modelo estudado. Esses resultados sugerem que homoenxertos descelularizados possam ter alguma capacidade regenerativa e com isso ter durabilidade superior aos homoenxertos criopreservados convencionais.