Simulating the ideal geometrical and biomechanical parameters of the pulmonary autograft to prevent failure in the Ross operation

OBJECTIVES: Reinforcements for the pulmonary autograft (PA) in the Ross operation have been introduced to avoid the drawback of conduit expansion and failure. With the aid of an in silico simulation, the biomechanical boundaries applied to a healthy PA during the operation were studied to tailor the best implant technique to prevent reoperation. METHODS: Follow-up echocardiograms of 66 Ross procedures were reviewed. Changes in the dimensions and geometry of reinforced and non-reinforced PAs were evaluated. Miniroot and subcoronary implantation techniques were used in this series. Mechanical stress tests were performed on 36 human pulmonary and aortic roots explanted from donor hearts. Finite element analysis was applied to obtain high-fidelity simulation under static and dynamic conditions of the biomechanical properties and applied stresses on the PA root and leaflet and the similar components of the native aorta. RESULTS: The non-reinforced group showed increases in the percentages of the mean diameter that were significantly higher than those in the reinforced group at the level of the Valsalva sinuses (3.9%) and the annulus (12.1%). The mechanical simulation confirmed geometrical and dimensional changes detected by clinical imaging and demonstrated the non-linear biomechanical behaviour of the PA anastomosed to the aorta, a stiffer behaviour of the aortic root in relation to the PA and similar qualitative and quantitative behaviours of leaflets of the 2 tissues. The annulus was the most significant constraint to dilation and affected the distribution of stress and strain within the entire complex, with particular strain on the sutured regions. The PA was able to evenly absorb mechanical stresses but was less adaptable to circumferential stresses, potentially explaining its known dilatation tendency over time. CONCLUSIONS: The absence of reinforcement leads to a more marked increase in the diameter of the PA. Preservation of the native geometry of the PA root is crucial; the miniroot technique with external reinforcement is the most suitable strategy in this context

Subcoronary implantation or aortic root replacement for human tissue valves: Sufficient data to prefer either technique?

The aortic root replacement technique with aortic allograft or pulmonary autograft might be superior to the subcoronary allograft implantation technique with regard to aortic regurgitation. We explored the influence of the learning process on the incidence of reoperation and the severity of postoperative aortic regurgitation as assessed by color Doppler echocardiography. The subcoronary implantation technique was used in 81 patients, and root replacement was done in 63 patients. The first 30 patients of each group were considered as the surgeons' learning curve. Reoperations were more common in the subcoronary implantation group. After exclusion of early reoperations, the median regurgitation score based on echocardiographic examination was 0.22 in the first 30 patients from the subcoronary implantation group and 0.14 in the root replacement group. The subsequent patients from these groups had regurgitation scores of 0.20 and 0.17, respectively. Statistical analysis of these data showed no significant difference. This interim report suggests that the learning curve for the surgical procedure and the grouping of echocardiographic data influence the interpretation of follow-up studies. The superiority of either technique with regard to aortic regurgitation has yet to be proved

Human tissue valves in aortic position: determinants of reoperation and valve regurgitation

BACKGROUND: Human tissue valves for aortic valve replacement have a limited durability that is influenced by interrelated determinants. Hierarchical linear modeling was used to analyze the relation between these determinants of durability and valve regurgitation measured by serial echocardiography. METHODS AND RESULTS: In adult patients, 218 cryopreserved aortic allografts were implanted with the subcoronary (85) or the root replacement technique (133), and 81 patients had root replacement with a pulmonary autograft. Mean follow-up was 4.2 years (SD 2.7; range, 0 to 10.5). Patient age, operator experience with subcoronary implantation, and allograft diameter were independent predictors for reoperation. With repeated color Doppler echocardiography, the severity of aortic regurgitation was assessed by the jet length method and the jet diameter ratio. Multilevel hierarchical linear modeling was used to estimate initial aortic regurgitation (intercept), its change over time (slope), and the effect of 11 potential determinants of durability on aortic regurgitation. With the jet length method, the intercept was 0.94 grade and the slope was 0.11 grade per year. With the jet diameter ratio, the intercept was 0.34 and the annual increase was 0.01. Subcoronary implanted valves had more initial aortic regurgitation, but progression of aortic valve regurgitation did not differ from root replacement. At midterm follow-up, recipient age <40 years was the only independent predictor of aortic regurgitation. CONCLUSIONS: Subcoronary implantation has a learning curve, resulting in more initial aortic regurgitation and early reoperation compared with root replacement. In both techniques, progression of aortic regurgitation over time is small but accelerated in young adults

Geometric models of the aortic and pulmonary roots: suggestions for the Ross procedure

Objective: To discuss geometric factors, which may influence long-term results relating to homograft competence following the Ross procedure, we describe the 3D morphology of the pulmonary and aortic roots. Materials: Measurements were made on 25 human aortic and pulmonary roots. Inter-commissural distances and the heights of the sinuses were measured. For geometrical reconstruction the three commissures and their vertical projections at the root base were used as reference points. Results: In the pulmonary root, the three inter-commissural distances were of similar dimensions (17.9±1.6mm, 17.5±1.4mm and 18.6±1.5mm). In the aortic root, the right inter-commissural distance was greatest (18.8±1.9mm), followed by the non-coronary (17.4±2.0mm) and left coronary sinus commissures (15.2±1.9mm). The mean height of the left pulmonary sinus was greatest (20±1.7mm) followed by the anterior (17.5±1.4mm) and right pulmonary sinus (18±1.66mm). In the aortic root, the height of the right coronary sinus was the greatest (19.4±1.9mm) followed by the heights of the non-coronary (17.7±1.8mm) and left coronary sinus (17.4±1.4mm). Measured differences between parameters determine the tilt angle and direction of the root vector. The tilt angle in the pulmonary root averaged 16.26°, respectively; for the aortic roots, it was 5.47°. Conclusions: Herein we suggest that the left pulmonary sinus is best implanted in the position of the right coronary sinus, the anterior pulmonary in the position of the non-coronary sinus and the right pulmonary sinus in the position of the left coronary sinus. In this way, the direction of the pulmonary root vector will be parallel to that of the aortic root vecto

Aortic valve surgery: Clinical studies after autograft, homograft and prosthetic valve replacement

Aortic Valve Surgery Clinical studies after autograft, homograft and prosthetic valve replacement Obaid Aljassim, MD Department of Cardiovascular Surgery and Anaesthesia, Sahlgrenska University Hospital and University of Gothenburg Introduction and Aims: Aortic valve disease in symptomatic adult patients often requires surgery. Several alternatives are available: repair, mechanical and biological prostheses, homograft and the Ross procedure. In the process of choosing valve substitute, the individual patient’s characteristics are matched against the characteristics of the different valve alternatives. This thesis includes clinical studies addressing outcome after the Ross procedure, after homograft replacement in endocarditis and Doppler versus catheter findings in patients with prosthetic valves. Methods: In Study I, surgical correction of autograft mismatch in the Ross operation (n=77) was investigated. In Study II we established the normal aortic dimensions using echocardiography in normal controls (n=38) and compared these findings with Ross operated patients (n=71) in a long-term follow up (101±31 mo). In Study III, patients with prosthetic (n=31) or native valve endocarditis with abscess (n=31) were operated with a homograft replacement, and followed for 37±11 months. In Study IV we investigated the flow resistance of mechanical and biological aortic valves using simultaneous Doppler and left ventricular and aortic pressure measurements (high-fidelity catheters). Results: Study I: Among the 24 patients without surgical correction an early moderate aortic regurgitation was present in eight patients (33%) compared with two of the following surgically corrected 53 patients (4%, p=0.001). Study II: A large proportion of the patients showed dilatation of the autograft (43%) and native aorta (32%) at late follow-up, and 5 were re-operated due to dilatation. There was a progression in both autograft and native aortic dimensions from the baseline to the follow-up. Only baseline autograft size did predict late dilatation (>4 cm). Study III: Nine patients (15%) died within 30 days. Variables associated with early mortality were higher Cleveland Clinic Risk Score (p=0.014), ECC-time (p=0.003), inotropic support (p=0.03), bleeding (p=0.01) and myocardial infarction (p<0.001). Cumulative survival was 82%, 78%, 75% and 67% at one, three, five and ten years, respectively. Quality of life (SF36) was not significantly different to a matched healthy control group. Study IV: There was a strong linear relation between catheter and Doppler gradients (r = 0.85 to 0.92). Doppler overestimated catheter gradients in both the mechanical and stented biological valve. Conclusions: Aortic regurgitation immediately after the Ross procedure can be minimized with surgical correction of anatomical mismatch in the aortic root. The autograft as well as the native aorta continues to dilate and this may lead to reoperation. Severe acute aortic endocarditis treated with homograft replacement is still associated with a substantial early complication rate and mortality. Long-term survival, quality of life and homograft function is satisfactory in patients surviving the immediate postoperative period. In the first in vivo study of the relation between Doppler and catheter gradients in prosthetic valves, we found a significant Doppler-catheter discrepancy in bioprostheses. Doppler overestimates the net gradients in both mechanical and biological prostheses

Ross procedure: is the root replacement technique superior to the sub-coronary implantation technique? Long-term results

There is controversy over the use of the Ross procedure with regard to the sub-coronary and root replacement technique and its long-term durability. A systematic review of the literature may provide insight into the outcomes of these two surgical subvariants. A systematic review of reports between 1967 and February 2013 on sub-coronary and root replacement Ross procedures was undertaken. Twenty-four articles were included and divided into (i) sub-coronary technique and (ii) root replacement technique. The 10-year survival rate for a mixed-patient population in the sub-coronary procedure was 87.3% with a 95% confidence interval (CI) of 79.7-93.4 and 89.1% (95% CI, 85.3-92.1) in the root replacement technique category. For adults, it was 94 vs 95.3% (CI, 88.9-98.1) and in the paediatric series it was 90 vs 92.7% (CI, 86.9-96.0), respectively. Freedom from reoperation at 10 years was, in the mixed population, 83.3% (95% CI, 69.9-93.4) and 93.3% (95% CI, 89.4-95.9) for sub-coronary versus root replacement technique, respectively. In adults, it was 98 vs 91.2% (95% CI, 82.4-295.8), and in the paediatric series 93.3 vs 92.0% (95% CI, 86.1-96.5) for sub-coronary versus root replacement technique, respectively. The Ross procedure arguably has satisfactory results over 5 and 10 years for both adults and children. The results do not support the advantages of the sub-coronary technique over the root replacement technique. Root replacement was of benefit to patients undergoing reoperations on neoaorta and for long-term survival in mixed serie

Phase I-II Trial of Foscarnet for Prevention of Cytomegalovirus Infection in Autologous and Allogeneic Marrow Transplant Recipients

The safety and efficacy of foscarnet for prevention of cytomegalovirus (CMV) infection was evaluated in 19 CMV-seropositive bone marrow transplant (BMT) recipients. All patients received intermittent intravenous (iv) foscarnet: 40 mg/kg every 8 h from 7 days before to day 30 after BMT, then 60 mg/kg once a day until day 75. The main toxicity was transient renal dysfunction, with a >50 µmol/L increase in serum creatinine above baseline in 5 of the 7 autograft recipients and in 6 of the 12 allograft recipients. Only 4 allograft recipients developed CMV infection during foscarnet prophylaxis, and no patient showed evidenceofCMV disease. Because 3 allograft recipients receiving concomitant iv amphotericin B showed rapid impairment of renal function, foscarnet prophylaxis should not be given to allograft recipients requiring amphotericin B; otherwise, foscarnet prophylaxis at this dose appears safe after BM