The pulmonary autograft after the Ross operation : results of 25 year follow-up in a pediatric cohort

Progressive autograft dilation and need for later reoperation remain major concerns of the Ross procedure. The study investigates the clinical outcome after the Ross operation, including a longitudinal analysis of autograft dimensions over 25 years. From November 1991 to April 2019, 137 patients underwent a Ross procedure at the University Hospitals of UCL (Université catholique de Louvain)-Brussels and Ghent. Inclusion criteria were less than or equal to 18 years of age and pulmonary autograft implantation by root replacement. Outcome focused on survival, reoperation rate, and autograft size evolution through linear mixed-model analysis. A Ross or Ross-Konno operation was performed in 110 (80%) and 27 (20%) patients at a median age of 10.4 (interquartile range [IQR], 4.7-14.3) years and 0.5 (IQR, 0.04-5.2) years, respectively. Overall 10-year and 20-year survival was 87% ± 3% and 85% ± 3%, respectively, but was 93% ± 3% for isolated Ross patients. Right ventricular outflow tract-conduit exchange was required in 20.3%, whereas autograft-related reoperation was performed in 14 (10.7%) patients at a median interval of 14 (IQR, 9-16) years, for aortic regurgitation (n = 2) and autograft dilation (n = 12). Autograft z-values increased significantly at the sinus and sinotubular junction (STJ) compared with the annulus (annulus = 0.05 ± 0.38/y, sinus = 0.14 ± 0.25/y, STJ = 0.17 ± 0.34/y; P = .015). The z-value slope for autograft dimensions was significantly steeper for Ross-Konno vs Ross patients (annulus: P = .029; sinus: P < .001; STJ: P = .012), and for children having aortic arch repair (annulus: P = .113, sinus: P = .038; STJ: P = .029). The Ross operation offers children requiring aortic valve replacement an excellent survival perspective, with an acceptable risk of autograft reoperation within the first 25 years. Contrary to the autograft annulus, dilation of the sinus and STJ size is of concern. Closer surveillance of autograft dimensions might be required in patients who underwent a Ross-Konno procedure or aortic arch reconstruction

The role of annular dimension and annuloplasty in tricuspid aortic valve repair†

OBJECTIVES: Valve sparing reimplantation can improve the durability of bicuspid aortic valve repair compared with subcommissural annuloplasty, especially in patients with a large basal ring. This study analyses the effect of basal ring size and annuloplasty on valve repair in the setting of a tricuspid aortic valve. METHODS: From 1995 to 2013, 382 patients underwent elective tricuspid aortic valve repair. We included only those undergoing subcommissural annuloplasty, valve sparing reimplantation or no annuloplasty and in whom intraoperative transoesophageal echocardiography images were available for retrospective pre- and post-repair basal ring measurements (n = 323, subcommissural annuloplasty: 146, valve sparing reimplantation: 154, no annuloplasty: 23). In a subgroup of patients with available echocardiographic images, basal ring was retrospectively measured at the latest follow-up or prior to reoperation. subcommissural annuloplasty and valve sparing reimplantation were compared after matching for degree of aortic regurgitation and root size. RESULTS: All three groups differed significantly for most of preoperative characteristics. Hospital mortality was 0.9%. The median follow-up was 4.7 years. At 8 years, overall survival was 80 ± 5%. Freedom from reoperation and freedom from aortic regurgitation >1+ were 92 ± 5% and 71 ± 8%, respectively. In multivariate analysis, predictors of aortic regurgitation >1+ were left ventricular end-diastolic diameter (P = 0.003), cusp repair (P = 0.006), body surface area (P = 0.01) and subcommissural annuloplasty (P = 0.05). In subcommissural annuloplasty, freedom from aortic regurgitation >1+ was lower for patients with basal ring ≥28 mm compared with patients with basal ring 1+ was independent of basal ring size (P = 0.38). In matched comparison between subcommissural annuloplasty and valve sparing reimplantation, freedom from aortic regurgitation >1+ was not significantly different (P = 0.06), but in patients with basal ring ≥28 mm, valve sparing reimplantation was superior to subcommissural annuloplasty (P = 0.04). Despite similar intraoperative reduction in basal ring size in subcommissural annuloplasty and valve sparing reimplantation, patients with subcommissural annuloplasty exhibited greater increase in basal ring size during the follow-up compared with the valve sparing reimplantation group (P < 0.001). CONCLUSIONS: As with a bicuspid aortic valve, a large basal ring predicts recurrence of aortic regurgitation in patients with tricuspid aortic valve undergoing repair with the subcommissural annuloplasty technique. This recurrence is caused by basal ring dilatation over time after subcommissural annuloplasty. With the valve sparing reimplantation technique, large basal ring did not predict aortic regurgitation recurrence, as prosthetic-based circumferential annuloplasty displayed better stability over time. Stable circumferential annuloplasty is recommended in tricuspid aortic valve repair whenever the basal ring size is ≥28 mm

The Ross procedure in young adults: over 20 years of experience in our Institution†

OBJECTIVES: The aim of this study was to evaluate the long-term outcomes following the Ross procedure in young adults in our institution. METHODS: All adult patients who received a Ross operation between 1991 and 2014 were included in the study. Survival analysis and regression analysis were performed. Survival of the Ross cohort was compared with the age-, gender- and calendar year-matched general population. RESULTS: Three hundred-and-six patients (mean age: 41.7 ± 9.7, male: 74.8%, bicuspid aortic valve: 58.5%, valve stenosis: 68%) were included in the analysis. There were 7 perioperative deaths (2.3%). Nine patients were lost to follow-up from hospital and completeness of the follow-up was 94%. The median follow-up of the remaining 290 patients was 10.6 years. There were 21 late deaths of which only 3 were valve-related. The overall survival at 15 years since surgery is 88 ± 3% that is comparable with the matched population. Freedom from valve-related deaths was 96.8 ± 2% at 16 years. Freedom from autograft and pulmonary homograft reoperation was 74.5 ± 4.3% at 16 years. Preoperative aortic regurgitation was the only significant predictor of autograft failure over time. Freedom from the combined end point of bleeding/thromboembolism/endocarditis/reoperation was 69.2 ± 4% at 16 years. Perioperative mortality following reoperation was 2.6% and the autograft could be spared in 72% of reinterventions. CONCLUSIONS: The Ross operation in young adults is associated with an excellent survival in the long term that is comparable with the general population. Although there is a risk of reoperation, incidence of other valve-related events is very low. The use of pulmonary autograft should be considered in any young adult patient requiring aortic valve replacement

Aortic valve repair with patch in non-rheumatic disease: indication, techniques and durability†

OBJECTIVES: To analyse the long-term outcomes of aortic valve (AV) repair with biological patch in patient with non-rheumatic valve disease. METHODS: From 1995 to 2011, 554 patients underwent elective (AV) repair; among them, 57 (mean age 45 ± 17 years) had cusp restoration using patch for non-rheumatic valve disease. Seven (12%) patients had unicuspid valve, 30 (53%) patients had bicuspid valve and 20 (35%) had tricuspid valve. Autologous pericardium was used in 26 patients (7 treated, 19 non-treated), bovine pericardium in 26, autologous tricuspid valve leaflet in 4 and aortic homograft cusp in 1. Patching was used to repair perforation (n = 20, 35%), commissural defect (n = 18, 32%), raphe repair (n = 17, 30%) or for cusp extension (n = 2, 3.5%). Echocardiographic and clinical follow-up was 98% complete and mean follow-up was 72 ± 42.5 months. RESULTS: No hospital mortality. At 8 years, overall survival was 90 ± 5% and freedom from valve-related death was 96 ± 3%. Two patients (3.5%) needed early reoperation for aortic regurgitation (AR); they underwent re-repair and the Ross procedure, respectively. Late reoperation was necessary in 9 patients (16%) for AR (n = 4), stenosis (n = 3) or mixed disease (n = 2). They had the Ross procedure (n = 6) or prosthetic valve replacement (n = 3) with no mortality. At 8 years, freedom from reoperation was 75 ± 9%. Freedom from reoperation was slightly higher in tricuspid compared with non-tricuspid valves (92 ± 7 vs 68 ± 11%, P = 0.18) and slightly higher for bovine (95 ± 5%) compared with autologous pericardium (73 ± 11%, P = 0.38), but differences were statistically not significant. In tricuspid valves, freedom from reoperation was higher in perforation repair compared with other techniques (100 vs 50 ± 35%, P = 0.02). In bicuspid valves, freedom from reoperation was similar between different repair techniques (P = 0.38). Late echocardiography showed AR 0-1 in 30 (53%) patients, AR 2 in 12 (21%) and no AR ≥ 3. Three patients presented a mean transvalvular gradient of 30-40 mmHg. Thromboembolic events occurred in 2 patients (0.6%/patient-year), bleeding events in 1 (0.3% /patient-year) and no endocarditis occurred. CONCLUSIONS: AV repair with biological patch is feasible for various aetiologies. The techniques are safe and medium-term durability is acceptable, even excellent for perforation repair in tricuspid valve morphology. Bovine pericardium is a good alternative to autologous pericardium

Surgery for complications of trans-catheter closure of atrial septal defects: a multi-institutional study from the European Congenital Heart Surgeons Association

Objective: This study aims to analyse the collective experience of participating European Congenital Heart Surgeons Association centres in the surgical management of complications resulting from trans-catheter closure of atrial septal defects (ASDs). Methods: The records of all (n=56) patients, aged 3-70 years (median 18 years), who underwent surgery for complications of trans-catheter ASD closure in 19 participating institutions over a 10-year period (1997-2007) were retrospectively reviewed. Risk factors for surgical complications were sought. Surgical outcomes were compared with those reported for primary surgical ASD closure in the European Association of Cardio-thoracic Surgery Congenital Database. Results: A wide range of ASD sizes (5-34mm) and devices of various types and sizes (range 12-60mm) were involved, including 13 devices less than 20mm. Complications leading to surgery included embolisation (n=29), thrombosis/thrombo-embolism/cerebral ischaemia or stroke (n=12), significant residual shunt (n=12), aortic or atrial perforation or erosion (n=9), haemopericardium with tamponade (n=5), aortic or mitral valve injury (n=2) and endocarditis (n=1). Surgery (39 early emergent and 17 late operations) involved device removal, repair of damaged structures and ASD closure. Late operations were needed 12 days to 8 years (median 3 years) after device implantation. There were three hospital deaths (mortality 5.4%). During the same time period, mortality for all 4453 surgical ASD closures reported in the European Association of Cardio-Thoracic Surgery Congenital Database was 0.36% (p=0.001). Conclusions: Trans-catheter device closure of ASDs, even in cases when small devices are used, can lead to significant complications requiring surgical intervention. Once a complication leading to surgery occurs, mortality is significantly greater than that of primary surgical ASD closure. Major complications can occur late after device placement. Therefore, lifelong follow-up of patients in whom ASDs have been closed by devices is mandator

Allogreffes et autogreffes valvulaires cardiaques dans le traitement des cardiopathies congénitales affectant les voies d'éjection droite et gauche

Dans les valvulopathies congénitales, les allogreffes valvulaires, aortiques et pulmonaires, représentent avec les autogreffes une alternative thérapeutique pour la correction chirurgicale des voies d’éjection du cœur. L’expérience initiale acquise avec ces valves, utilisées isolément ou associées à leur tronc artériel, a été décevante en raison de l’apparition précoce de dégénérescence tissulaire et de calcifications attribuées aux méthodes de stérilisation et de conservation. Ces méthodes faisaient appel aux bêta-propionolactones pour la stérilisation et à la glutaradehyde pour la fixation [TALMAN188]. Ces complications engendrèrent une vague de désintérêt pour les allogreffes tandis qu’elles contribuèrent au succès des valves d’origine animale – hétérogreffes – et des conduits valvulés à l’aide de ces valves ou même de valves mécaniques. Les résultats ne furent guère plus probants, avec l’apparition de lésions dégénératives responsables de sténoses et de réinterventions [SCHOEN 173], d’autant plus précocement que le patient était plus jeune [SANDERS 169 et WILLIAMS 200], favorisant par la même occasion le retour à l’utilisation des prothèses mécaniques. Une modification profonde des méthodes de préparation des allogreffes valvulaires, basée sur la stérilisation par les antibiotiques et une conservation par la cryopréservation a suscité un regain d’intérêt [O’BRIEN 137, 138] et a contribué à l’essor de banque d’allogreffes [MERMET 131, O’BRIEN 138, RUFFIE 166], dont la première banque d’allogreffes cryopréservées en Belgique créée à l’U.C.L. en 1983. En position droite, les allogreffes pulmonaires cryopréservées présentent de multiples caractéristiques susceptibles d’en faire un substitut préférentiel. Aucune anticoagulation n’est nécessaire et la constitution tissulaire identique à celle du tissu receveur en facilite l’implantation. Leur flexibilité permet l’insertion de plus grands diamètres et leur sensibilité aux calcifications est moindre grâce à leur architecture histologique. A dimension égale, leur profil hémodynamique est plus favorable que celui des allogreffes aortiques. Le tronc artériel pulmonaire est un conduit naturellement bifurqué qui autorise une implantation éventuelle sur les branches pulmonaires [BANDO 9 et DAENEN 37]. Leur croissance n’a toutefois pas été démontrée. Dans le traitement de la tétralogie de FALLOT, CLARKE et coll. [28] préconise l’utilisation d’une allogreffe valvulaire pulmonaire de première intention, en alternative à la plastie transannulaire élargissante de la chambre de chasse du ventricule droit et de l’artère pulmonaire. Afin d’éviter cette dernière éventualité ou de retarder la mise en place d’une allogreffe, notre équipe a introduit un protocole de dilatation annulaire par angioplastie percutanée visant à développer la voie artérielle pulmonaire [SLUYSMANS 182]. Dans le traitement des séquelles pulmonaires de la chirurgie de la tétralogie de Fallot, nous avons adopté un protocole de valvulation par allogreffes valvulaires pulmonaires. En position gauche, le remplacement valvulaire aortique chez l’enfant par une prothèse mécanique ou une hétérogreffe confronte le clinicien avec une variété considérable de problèmes : la croissance de l’enfant et son corollaire, le risque de réintervention, les contraintes hémodynamiques liées aux prothèses de petite dimension, leurs caractères palliatifs ou dégénératifs, les risques liés à l’usage à long terme de médications anticoagulantes et les risques infectieux. Les hétérogreffes dégénèrent rapidement chez les enfants, d’autant plus vite qu’elles sont implantées ç un plus jeune âge [SANDERS 169 et WILLIAMS 2000]. L’emploi de prothèses mécaniques donne des résultats globalement satisfaisants [BAUDET 10], abstraction faite du risque opératoire et des risques d’accidents thrombo-emboliques [SADE 167]. Elles demeurent une procédure majeure, surtout chez l’enfant en bas âge [KONNO 109 et RUBAY 162]. La mise ne place d’une prothèse en position aortique, généralement de petite dimension et, souvent au prix de plasties d’élargissement de l’anneau [KONNO 109], conduit immanquablement à un remplacement à l’adolescence en raison de la croissance. La sévérité de ce geste, surtout chez l’enfant en bas-âge, a fortement contribué à l’essor des valvuloplasties percutanées, gestes palliatifs et itératifs, visant à postposer la mise en place d’une prothèse mécanique. L’amélioration de la qualité du prélèvement et de la conservation des allogreffes a conduit à un regain d’intérêt pour ces valves en position gauche [O’BRIEN 137, 138]. Leur profil hémodynamique et leur résistance à l’infection [HAYDOCK 74, McGRIFFIN 129, O’BRIEN 140] ont été largement démontrés et leur diffusion s’est répendue grâce aux banques d’allogreffes. Leur utilisation s’adresse aux adultes jeunes, présentant des valvulopathies aortiques, souvent séquellaires de lésions congénitales. Leur potentiel dégénératif et leur absence de croissance ont freiné leur mise en place chez l’enfant [LANGLEY 117, O’BRIEN 140]. La familiarisation avec les techniques d’implantation de ces valves a favorisé la réactualisation de l’opération de ROSS [156], au cours de laquelle la valve aortique pathologique est remplacée par la valve pulmonaire du patient. Cette technique d’autogreffe pulmonaire refait actuellement surface au sein des équipes les plus audacieuses. L’opération de Ross illustre la synthèse de l’approche thérapeutique des valvulopathies congénitales puisqu’elle autorise la croissance de l’enfant, la valve se développant avec lui, et permet l’abstention de toute thérapeutique anticoagulante. L’autogreffe, constituée de tissu vivant, garde une plus grande résistance à l’infection et n’est soumise à aucun processus dégénératif. Elle constitue un substitut avantageux et peut-être définitif en position gauche [ROSS 158]Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 199