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How to cite: Konertz W. (1997). Hemodynamic performance of the Edwards Prima stentless valve. The Journal of heart valve disease, 6(4), 441–442.

The right and left venous valves of the sinoatrial orifice regulate the flow of blood from the sinus venosus to the atrium in pisces, amphibians, and reptiles. In aves, mammals and humans, the venous valve loses its hemodynamic function and hence has become the 'Cinderella' among heart valves, receiving attention only when congenital anomalies occur that are related to it. The right venous valve persists in humans as the crista terminalis, Eustachian and Thebesian valves. An intraluminal muscle band is described located inside the right atrium, and coursing in the line of the crista terminalis between the septum spurium and inferior vena cava. This abnormal band is possibly derived from the right venous valve.

How to cite: Victor, S., & Nayak, V. M. (1997). An anomalous muscle bundle inside the right atrium possibly related to the right venous valve. The Journal of heart valve disease, 6(4), 439–440.

Background and aims of the study: There is increasing interest in the use of stentless porcine bioprostheses implanted by the free-hand suturing technique. However, preservation of normal valve geometry and function is a matter of concern. This in vitro study was conducted to investigate the influence of sizing and method of fixation in glutaraldehyde on the hydrodynamic function of stentless, free-hand inserted porcine bioprosthetic valves in the aortic position.

Methods: Three sets of porcine aortic roots were used, with six specimens in each set. Group A comprised 2-3 mm larger aortic valve (oversizing) fixed in glutaraldehyde under zero pressure inserted by free-hand suturing technique in fresh aortic roots; group B comprised size-for-size placement of aortic valve fixed in glutaraldehyde under zero pressure inserted by free-hand suturing technique in fresh aortic roots; and group C comprised size-for-size placement of aortic valve fixed in glutaraldehyde under zero pressure with permanent predilatation before fixation inserted by free-hand suturing technique in fresh aortic roots (undersizing). Hydrodynamic function and leaflet bending deformations were analyzed in a modified pulsatile flow simulator which incorporated the elastic aortic roots.

Results: The hydraulic effective orifice area (EOA) of the valve (derived from flow and pressure measurements) was divided by actual orifice area of the annulus to determine the performance index. Although statistically non-significant, the performance index of 0.50 in group A (oversizing) was higher than that of size-for-size placement in group B (0.39). The performance index in group C of 0.41, following use of a permanent predilatation technique, was again not significantly different. The mean pressure difference during peak flow followed a correspondingly reversed order, with 11.4 mmHg in group B, 8.86 mmHg in group C, and 7.75 mmHg in group A. No significant difference was observed between the groups in terms of open leaflet bending deformations, nor was there any inter-group difference in regurgitation.

Conclusions: No beneficial effect was seen to suggest that size-for-size placement was superior to the currently followed practice of over-sizing. In contrast to previous studies of whole root replacement, permanent predilatation and fixation was also not shown to have any additional advantages in a stentless scalloped free-hand inserted porcine valve.

How to cite: Revanna, P., Fisher, J., & Watterson, K. G. (1997). The influence of sizing and method of fixation on the hydrodynamic function of stentless, free-hand inserted porcine bioprosthesis: an in vitro study. The Journal of heart valve disease, 6(4), 433–438.

Background and aims of the study: Porcine bioprosthetic heart valves (PBHV) continue to suffer from limited long-term durability. Failure of PBHV occurs mainly in the cusps and is characterized by mechanical damage, usually in conjunction with calcification. Mechanisms underlying calcification have received considerable attention, yet mechanical damage phenomena remain poorly understood. The structural response of PBHV cusps to in-vivo cyclic loading involves three primary factors: (i) mechanical properties; (ii) fiber architecture; and (iii) 3D geometry. Previous finite element studies have shown cuspal stress distribution to be highly sensitive to subtle changes in geometry, yet to date, cusp geometry has been largely ignored in studies of PBHV durability.

Methods: A non-destructive method was developed to quantify PBHV 3D geometry using high-resolution magnetic resonance (MR) imaging. Images were obtained in three orthogonal planes from virgin and accelerated tested (50 x 10(6) and 200 x 10(6) cycles) PBHVs to fully capture 3D cuspal geometry. Surface curvatures were computed using a local biquadric surface patch approach.

Results: Results indicated a tendency for cusps to permanently deform with accelerated testing, manifesting primarily as sagging of the cusp. This sagging induced areas of high curvature from the central belly region upwards to the nodulus of Aranti, corresponding to known locations of tissue failure.

Conclusions: It is likely that the observed changes in cuspal geometry induce deleterious alterations in the stress distribution, independent of those related to mechanical properties and fiber structure, and contribute to valve failure. Our results suggest that PBHV designers should attempt to compensate for the deleterious geometric changes that occur post-implantation.

How to cite: Smith, D. B., Sacks, M. S., Pattany, P. M., & Schroeder, R. (1997). High-resolution magnetic resonance imaging to characterize the geometry of fatigued porcine bioprosthetic heart valves. The Journal of heart valve disease, 6(4), 424–432.

Background and aims of the study: Photooxidation of pericardium has been shown chemically to alter and stabilize tissue. The characterization of photooxidatively induced, chemical modifications of bovine pericardial and arterial tissue is reported here.

Methods: Tissues were prepared by various methods of photooxidation and analyzed for thermal denaturation temperature, protein extraction, amino acid content and crosslink content.

Results: Photooxidation of tissue resulted in no significant time-dependent changes in thermal denaturation temperature, but did result in a time-dependent alteration and reduction in extracted proteins. This reduction is consistent with chemical alteration and stabilization of the tissue. Photooxidation also resulted in a time-dependent reduction of histidine content in treated tissues by histidine being converted to a non-detectable form. No other amino acid alteration was detected by amino acid analysis. Crosslink analysis of tissue hydrolyzates showed a time-dependent alteration in crosslink content of photooxidized tissue and an apparent addition of several types of new crosslinks.

Conclusions: These chemical modifications are consistent with oxidative modification of amino acids in the tissues, resulting in an alteration of existing crosslinks and possible addition of new crosslinks in the tissues. This treatment process leads to in vivo and in vitro stability of pericardial and arterial tissues with potential use as bioprosthetic materials.

How to cite: McIlroy, B. K., Robinson, M. D., Chen, W. M., & Moore, M. A. (1997). Chemical modification of bovine tissues by dye-mediated photooxidation. The Journal of heart valve disease, 6(4), 416–423.

Background and aims of the study: To determine the short-term results of the Bicarbon (Sorin Biomedica, Saluggia, Italy) heart valve prosthesis at our institution.

Methods: Between November 1991 and December 1995, 256 patients (mean age 59.9 +/- 9.8 years) underwent valve replacement with a Bicarbon valve prosthesis. The mean ejection fraction was 60 +/- 14.8% and the mean left ventricular end-diastolic pressure 15.9 +/- 8.7 mmHg. Redo (n = 61) and combined procedures (n = 72) were included in this study; mixed types of prostheses were excluded. The procedures were divided into groups: aortic valve replacement (n = 163), mitral valve replacement (n = 60) and aortic-mitral (double) valve replacement (n = 33). Kaplan-Meier survival analysis was performed and predictors for survival were tested univariately and multivariately.

Results: The mean follow up was 30 +/- 25.1 months with a total of 7,696 patient-months (641.3 patient-years) and was 100% complete. The Kaplan-Meier survival rate at 48 months was 87 +/- 2%. The valve-related morbidity expressed as linearized incidence rate (% per patient-year) was: anticoagulation bleeding 2.3 +/- 0.6; thromboembolic event 1.0 +/- 0.4; periprosthetic leak 0.6 +/- 0.3; and endocarditis 0.3 +/- 0.2. Univariate significant factors for worse survival were: higher preoperative New York Heart Association (NYHA) functional class, valve implantation site, presence of associated operation, increasing age, decreasing ejection fraction, longer aortic cross-clamp time, and longer cardiopulmonary bypass time. In multivariate analysis longer aortic cross-clamp time and higher preoperative NYHA classification were significant independent predictors.

Conclusions: These good short-term results after Bicarbon valve replacement are encouraging and comparable with those obtained with other bileaflet mechanical heart valves. However, further follow up is mandatory.

How to cite: Casselman, F., Herijgers, P., Meyns, B., Flameng, W., & Daenen, W. (1997). The Bicarbon heart valve prosthesis: short-term results. The Journal of heart valve disease, 6(4), 410–415.

Background and aims of the study: Little comparative information exists on the outcome of the valve replacement with bioprostheses or mechanical valves in the elderly. This study was carried out to make such a comparison.

Methods: Follow up data were examined from 219 patients aged > or = 65 years who underwent aortic and/or mitral valve replacement using bioprosthetic (n = 67) or mechanical valve (n = 152) between April 1979 and December 1993. The mean follow up periods were 6.3 +/- 2.8 years after bioprosthesis and 4.9 +/- 2.1 years after mechanical valve implantation.

Results: Although the actuarial rate of structural deterioration was higher in patients with bioprosthetic valves than in those with mechanical valves (58% versus 100% freedom at 10 years after surgery, p < 0.01), no such prosthesis-related difference was seen in the subgroup of patients aged > or = 70 (100% versus 100% at nine years, p = N.S.). The actuarial rate of major bleeding was higher after mechanical valve implantation than after bioprosthetic valve placement (90% versus 100% freedom at 10 years, p < 0.05); this lower rate with bioprosthetic valves was maintained in patients aged > or = 70 (78% versus 100% at nine years, p < 0.05). There were no significant differences in the incidences of thromboembolism and bacterial endocarditis between the two valve types.

Conclusions: Structural degeneration of bioprosthetic devices was a major problem in patients aged 65-70 years, but it was essentially negligible in those aged > or = 70 years. Anticoagulant-related bleeding was a major problem with mechanical valves in both age groups. Therefore, for patients older than 70 years, valve replacement with a bioprosthesis appears to be the method of choice.

How to cite: Kobayashi, Y., Eishi, K., Nagata, S., Nakano, K., Sasako, Y., Kobayashi, J., Kosakai, Y., & Miyatake, K. (1997). Choice of replacement valve in the elderly. The Journal of heart valve disease, 6(4), 404–409.

Background and aims of the study: To investigate the influence of different surgical techniques of chordal preservation in mitral valve replacement (MVR) on left ventricular size and function, we studied a series of 244 patients who underwent mitral valve replacement either with (n = 161) or without (n = 83) preservation of the subvalvular structures.

Results: Preoperatively there were no differences between the two patient groups. Three months postoperatively, echocardiography demonstrated that chordal preservation in MVR resulted in smaller left ventricular end-systolic diameter (LVESD) and end-diastolic diameter (LVEDD): preservation versus resection, LVESD: 43.4 +/- 7.8 mm versus 48.8 +/- 9.2 mm (p < 0.05), LVEDD: 57.3 +/- 7.8 mm versus 62.9 +/- 10.5 mm (p < 0.05) and a significantly decreased LV-L (long axis) (87.1 +/- 4.2 mm versus 97.5 +/- 5.7 mm; p < 0.05). There was no significant difference in cardiac dimensions between the three patient subgroups in whom chordal preservation was possible. In addition, left ventricular ejection fraction in the preservation groups was significantly improved compared with the resection group (54.2 +/- 11.2% versus 48.1 +/- 12.4%, p < 0.05); there were no differences between the preservation subgroups. Regional wall motion analysis revealed significantly improved segmental myocardial performance in all segments if both leaflets were preserved or the anterior mitral leaflet was reattached to the anterior mitral annulus.

How to cite: Straub, U. J., Huwer, H., Kalweit, G., Volkmer, I., & Gams, E. (1997). Improved regional left ventricular performance in mitral valve replacement with orthotopic refixation of the anterior mitral leaflet. The Journal of heart valve disease, 6(4), 395–403.

Background and aims of the study: Despite many significant improvements in cardiac surgical technique, the operative risk for combined aortic and mitral valve surgery remains between 5% and 12%. Identification of high-risk patients will allow surgeons to develop strategies to improve these results.

Methods: The 30-day postoperative mortality and complication rates were analyzed in a group of 206 patients operated on over a 16-year period with cold crystalloid cardioplegia. Thirty-three possible risk factors for death and low output syndrome (LOS) were entered into univariate and multivariate logistic regression analysis.

Results: There were 10 perioperative deaths (4.9%). Major complications occurred in 38 patients (18.4%), 19 with LOS. On univariate analysis, right atrial pressure (RAP) > or = 8 mmHg (p = 0.001), aortic stenosis (p = 0.009) and systolic pulmonary artery pressure > or = 60 mmHg (p = 0.095) were found to be risk factors for death, as were RAP > or = 8 mmHg (p = 0.001), previous heart surgery (p = 0.007), serum creatinine > or = 120 mumol/l (p = 0.03), tricuspid valve disease (p = 0.038) and aortic stenosis (p = 0.09) for LOS. On multivariate analysis, RAP > or = 8 mmHg (p < 0.001) and aortic stenosis (p = 0.002) were identified as independent risk factors for death, as were RAP > or = 8 mmHg (p = 0.001) and previous heart surgery (p = 0.008) for LOS.

Conclusions: Mitro-aortic valve surgery involves complex procedures with substantial mortality and morbidity. The risk factors point toward the importance of operating before the stage of advanced heart failure and toward the key role of better myocardial protection techniques in these compromised hearts with limited reserves.

How to cite: Mueller, X. M., Tevaearai, H. T., Ruchat, P., Hurni, M., Fischer, A. P., Stumpe, F., & von Segesser, L. K. (1997). Perioperative morbidity and mortality in combined aortic and mitral valve surgery. The Journal of heart valve disease, 6(4), 387–394.

Background and aims of the study: In patients with mitral regurgitation, left ventricular angiography is usually performed to grade the regurgitation. This is a semi-quantitative method which gives some information related to the regurgitant volume at a certain time. The aim of our study was to evaluate the benefits of invasive hemodynamic examinations during stress. Patients with mitral regurgitation according to Doppler color flow mapping, and regurgitation of no more than grade 2+ according to left ventricular angiography, were of special interest.

Methods: One hundred and four consecutive patients were examined with transesophageal echocardiography (TEE), left ventricular angiography and cardiac catheterization during rest and during hemodynamic stress.

Results: All patients had mitral regurgitation according to Doppler color flow mapping. Thirty eight patients had a mitral regurgitation of grade 0, 1+ or 2+ according to left ventricular angiography. Of these, seven had a resting v-wave < or = 25 mmHg, and a v wave > or = 50 mmHg during stress. When these seven patients were compared with those with severe grade 3+ and 4+ regurgitation, there was a significant difference between the v-wave at rest (p = 0.02) but no significant difference during stress (p = 0.42).

Conclusions: Mitral regurgitation is a dynamic lesion, the complete assessment of which cannot be obtained from a single measure during one hemodynamic situation. Additional information from v-wave recordings during hemodynamic stress identified a subgroup of patients who had near-normal pressures at rest, but whose v-wave measurements during stress did not differ significantly from those of patients with severe angiographically assessed regurgitation (grades 3+ and 4+). In patients with only minor mitral regurgitation which is suspected to contribute to their clinical symptoms, the monitoring of invasive hemodynamic parameters during stress is important.

How to cite: Holm, S., Frithiof, D., Teien, D., & Karp, K. (1997). Invasive evaluation of mitral regurgitation: the importance of hemodynamic measurements during exercise. The Journal of heart valve disease, 6(4), 383–386.

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How to cite: Takeda, S., Rimington, H., & Chambers, J. (1997). Hemodynamic assessment of replacement valves in the aortic position: is stress echocardiography necessary?. The Journal of heart valve disease, 6(4), 380–382.

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How to cite: Frater R. W. (1997). Repair versus replacement for mitral stenosis. The Journal of heart valve disease, 6(4), 377–379.

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How to cite: Duran C. M. (1997). The wisdom of repairing stenotic mitral lesions. The Journal of heart valve disease, 6(4), 375–376.

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How to cite: David T. E. (1997). The appropriateness of mitral valve repair for rheumatic mitral valve disease. The Journal of heart valve disease, 6(4), 373–374.

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How to cite: Cotrufo, M., Vitale, N., Cafarella, G., & De Feo, M. (1997). Valve repair in rheumatic mitral valve disease: is it always worth trying?. The Journal of heart valve disease, 6(4), 370–372.

Background and aims of the study: Aortic root replacement with the pulmonary autograft has become an alternative to replacement of the diseased aortic valve with mechanical or biological prostheses. Due to greater technical complexity of the operation, complications with autograft root replacement (ARR) may be more common. In particular, a higher prevalence of coronary complications has been suggested.

Methods: In order to assess the prevalence, cause and management of coronary complications after ARR, results with 26 consecutive operations were reviewed and compared with previously published series. Between July 1994 and Apri 1997, 22 males and four females (mean age 26 +/- 8 years; range: 11 to 36 years) underwent aortic root (n = 22) or valve replacement (n = 4) with a pulmonary autograft for regurgitation (n = 14), stenosis (n = 4) or both (n = 8). Associated lesions were present in 10 (38%) patients, including three cases of major coronary artery anomalies such as origin of the circumflex from the right coronary sinus, high origin of the right coronary, aneurysmal and calcified right and left main coronaries, both in one patient.

Results: There were no early deaths. Major complications occurred in six patients; re-exploration for bleeding was required in three (11%) and partial take down of repair for coronary complications in three (11%), all with preoperative coronary anomalies. Two of the latter patients presented with intraoperative right ventricular ischemia due to kinking of the right coronary (corrected by re-implantation at a higher level), and one had intraoperative hemorrhage due to rupture of a calcified left main coronary, which required transection of the pulmonary homograft above the valve to expose the tear. Recovery was prompt in all patients (mean ICU stay 35 +/- 28 h) with no metabolic or electrocardiographic evidence of ischemia. Echocardiography at discharge showed satisfactory biventricular kinetics in all; mild regurgitation of the autograft was found in two (8%) who had undergone subcoronary implant, and absent or trivial in 22 (92%). One patient died suddenly 13 months after ARR; hence actuarial survival rate was 100% and 96% at 12 and 24 months, respectively. At mean follow up of 15 +/- 11 months (range 1 to 32 months), all patients are in NYHA class I and have returned to school or prior employment.

Conclusions: Complications with coronary artery translocation during ARR may be a definite risk, particularly in the presence of coronary anomalies. Prompt recognition and an aggressive intraoperative approach, including partial take down of the repair, may limit the morbidity of this complex surgical procedure.

How to cite: Luciani, G. B., Santini, F., Pessotto, R., Fabbi, A., & Mazzucco, A. (1997). Coronary translocation during aortic root replacement with the pulmonary autograft: complications and their management. The Journal of heart valve disease, 6(4), 361–369.

Background: The pulmonary autograft operation has achieved broad acceptance and may be the ideal aortic valve substitute. Both the pulmonary autograft and the aortic homograft are more complicated procedures than prosthetic valve replacement. The trend to insert the pulmonary autograft as a root replacement rather than in the subcoronary position has achieved greater uniformity in the results, but there is still confusing diversity in opinions on technical details and anatomical dimensions. The importance of both size and shape mismatches between the three valves involved has received little attention. The valves often differ in diameter and in the shape of the recipient aortic annulus. This uncertainty and the diversity of opinions on essential technical details was disconcerting when we proceeded from aortic homograft-to-pulmonary autograft operations, this was compounded by only a single homograft being available for every operation as we have no homograft bank.

Methods: We compared the hemodynamic results regarding various geometric mismatches. All operative details were the same and patients were studied at regular intervals. Comparisons were made in patients with mismatch between recipient aortic annulus and pulmonary autograft. Patients with a normal tricuspid aortic annulus were compared to those with either a circular redo prosthetic valve annulus or a bicuspid recipient annulus. Thirdly we compared the patients with plication of the aortic annulus to those with remodeling of the distal aorta. Lastly we compared mismatch between donor homograft and pulmonary autograft.

Results: No influence of geometric mismatch between the three valves could be found on the results of the pulmonary autograft operation.

Conclusions: Good results are obtainable without a painful learning curve if one keeps to certain surgical principles. It need not be a complicated operation and geometric mismatches between the three valves involved may be compensated for adequately.

How to cite: Botha, C. A., Roser, D., Rupp, W., Paula, J. A., Kolb, I. E., Böhm, J. O., Langenbeck, D., & Rein, J. G. (1997). The influence of geometric mismatch between the native aortic, native pulmonary and homograft pulmonary valve on the results of the pulmonary autograft operation. The Journal of heart valve disease, 6(4), 355–360.

Background of the study: Between February 1987 and December 1996, 187 children and young adults underwent right ventricular outflow tract (RVOT) reconstruction with aortic or pulmonary homografts.

Methods: Patients were allocated to four groups according to preoperative diagnosis: RVOT obstructions with ventriculo-arterial (VA) concordance (n = 90), RVOT obstructions with VA discordance (n = 26), truncus arteriosus (n = 19) and RVOT reconstruction after the Ross procedure (n = 52). RVOT reconstruction was a reoperation in 49.7% of cases. A pulmonary homograft was used in preference (87% in concordant, 90% in Ross, 79% in truncus, and 50% in discordant groups).

Results: Five patients died after homograft repair (hospital mortality rate 2.7%). Mean follow up was 34 +/- 27 months. Four patients died during subsequent follow up; hence actuarial survival rate was 93 +/- 2% at 60 months. All other patients are currently in NYHA class I or II. Nine patients underwent reoperation because of homograft dysfunction. Overall survival was 90 +/- 3% at 60 months.

Conclusions: Uni- and multivariate analysis identified young age at correction, the use of aortic homografts, corrections in patients with VA discordance, and longer aortic cross-clamp time as independent predictors of homograft failure.

How to cite: Daenen, W., & Gewillig, M. (1997). Factors influencing medium-term performance of right-sided cryopreserved homografts. The Journal of heart valve disease, 6(4), 347–354.

Background and aims of the study: Although pulmonary autograft (PA) offers many theoretical advantages, the operation is more complex and the need for extensive reconstruction carries an increased risk for postoperative bleeding. The study aim was to evaluate the impact of different pharmacological and surgical strategies on total blood loss and blood product requirements after PA use.

Methods: Between July 1994 and March 1997, 26 patients (22 males) with a mean age of 26 +/- 8 years (range: 11 to 36 years) underwent aortic valve replacement with PA (22 root; four subcoronary implant). A relatively high incidence of re-exploration for bleeding (n = 3) and significant total blood loss during our early experience (Group I, n = 8), prompted the subsequent introduction of different strategies (Group II, n = 18). These included perioperative use of aprotinin, reinforcement of suture lines of the neo-aortic root with autologous pericardium and accurate hemostasis of the raw surface on the back of the right ventricular outflow tract (RVOT) during a brief period of circulatory arrest, also with application of fibrin glue,

Results: There were no hospital deaths. No patients in group II required re-exploration or transfusion, and mean total postoperative blood loss was reduced (group I, 720 +/- 465 ml/m2 body surface area (BSA), versus group II, 323 +/- 84 ml/m2 BSA). By-pass and aortic cross-clamp times were not significantly longer in group II patients. At a mean follow up of 15 months, all 25 survivors are asymptomatic, in NYHA functional class I, and with normal social interactions.

Conclusions: Early survival after aortic valve replacement with the PA appears comparable with the use of more conventional valve substitutes. Blood loss containment by routine application of medical and surgical strategies appears feasible. In view of the common concern about blood transfusion, particularly in young patients, these findings may help to widen the range of indications for the Ross procedure.

How to cite: Santini, F., Luciani, G. B., Pessotto, R., Petrilli, G., Fabbri, A., & Mazzucco, A. (1997). Current techniques to reduce blood loss after the Ross procedure. The Journal of heart valve disease, 6(4), 343–346.

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How to cite: Ross D. N. (1997). Pulmonary autografts: the unresolved issues. The Journal of heart valve disease, 6(4), 330–332.

Methods: Thirty-three children and young adults with congenital aortic valve disease underwent pulmonary autograft replacement of the aortic valve between October 1993 and March 1997. There wer six females and 27 males; at operation, median age was 16 years (range: 3 to 41 years) and median body weight 60 kg (range: 14 to 121 kg). Fifteen patients (46%) had undergone one or more previous cardiac surgical procedures. A bicuspid aortic valve was present in 31 patients (94%); moderate to severe aortic stenosis and regurgitation was present in 10 (30%) and 26 (79%), respectively.

Results: All patients underwent the Ross procedure while in NYHA class I (64%) or class II (36%). A preoperative shortening fraction of 41 +/- 1.4% suggested well-preserved systolic function, but the mean left ventricular end-diastolic pressure of 16.6 +/- 1.3 mmHg was consistent with preoperative left ventricular pressure and volume overload. The aortic root was replaced using an interrupted suture technique in two patients and with three separate running sutures in 31. The right ventricular outflow tract was reconstructed in all classes with a cryopreserved pulmonary homograft valved conduit (median diameter 23 mm; range 19 to 30 mm). Intraoperative complications included transient atrioventricular dissociation (one), permanent atrioventricular dissociation (one), and left coronary artery distortion relieved by shortening the distal ascending aorta (one). Postoperatively, postpericardiotomy syndrome developed in six patients (18%), supraventricular tachycardia in three (9%), and ventricular tachycardia in one (3%). At three days after surgery, one patient developed ischemic left ventricular dysfunction requiring repositioning of the distorted left coronary artery higher on the neo-aortic root. Hospital survival rate was 100%. During a median follow-up of 17 months (range: 1 to 41 months) one patient suffered a non-cardiac death due to blunt trauma. there has been a significant postoperative improvement in NYHA class among surviving patients (class I, 94%; class II, 6%; p = 0.004 versus preoperative). Postoperative aortic regurgitation was absent or trivial in 17 (60%) and mild in the remaining 11 (40%) patients for whom follow-up echocardiographic data are available. One patient required reoperation 16.5 months after the Ross procedure to replace a rapidly degenerating pulmonary homograft, and one with moderately severe homograft stenosis and five with mild homograft stenosis are being monitored. Postoperatively, a gradual early expansion in the diameter of the neo-aortic root and reduction in echocardiographic indices of left ventricular hypertrophy and dilatation occurred.

Conclusions: Pulmonary autograft replacement of the aortic valve in young patients with congenital aortic valve disease has produced excellent short-term anatomic/physiologic results and symptomatic relief with no mortality. Indices of left ventricular dilatation and hypertrophy regress after repair when the Ross operation precedes important deterioration in preoperative ventricular function. Important technical considerations include: (i) the native distal ascending aorta should be sufficiently shortened before performing the distal aortic anastomosis; and (ii) the left coronary anastomosis should be positioned relatively high on the neo-aortic root with a slight amount of tension. Both of these maneuvers reduce the likelihood of coronary artery distortion. Rapid degeneration of the pulmonary homograft and the propensity towards progressive dilatation of the neo-aorta are important postoperative considerations. Until more is known about the etiology and natural history of these two potential complications, postoperative anti-inflammatory and/or immunosuppressive therapy and strict control of hypertension should be strongly considered.

How to cite: Walters, H. L., 3rd, Lobdell, K. W., Tantengco, V., Lyons, J. M., Hudson, C. L., Struble, S. L., & Hakimi, M. (1997). The Ross procedure in children and young adults with congenital aortic valve disease. The Journal of heart valve disease, 6(4), 335–342.