Bozok, S.

Ilhan, G.

Kestelli, M.

Lafci, B.

European Journal of Cardio-Thoracic Surgery

S. Bozok

M. Kestelli

G. Ilhan

B. Lafci

Crossref

The causes of re-operation in the Ross procedure

Bozok, Şahin

Kestelli, Mert

İlhan, Gökhan

Lafcı, Banu

DSpace @ Recep Tayyip Erdoğan Üniversitesi Akademik Açık Arşiv

We read with interest the article by Chapman et al. [1]. Theyshowed that patients receiving recombinant factor VIIa (rFVIIa)for intractable bleeding after cardiac surgery are not at anincreased risk of thromboembolic events. Therefore, they con-cluded that this effective haemostatic agent can be used with anacceptable safety profile in this patient population. We wouldlike to ask the authors whether, among the 236 patients receiv-ing rFVIIa, they had patients supported by extracorporeal mem-brane oxygenator (ECMO).Bleeding is a major problem in postoperative ECMO implan-tation for post-cardiotomy cardiogenic shock [2]. Severe haemor-rhage requiring re-exploration occurs in up to 58% of cases [3]and carries a dismal prognosis. Among patients who returned tothe operating theatre, a surgical source of bleeding is not ident-ified in more than half of the patients [1]. Hence, the off-labeluse of rFVIIa represents an attractive haemostatic agent for con-trolling bleeding attributed to a disseminated intravascularcoagulation-like phenomenon [4].We entirely agree with their opinion about the effectivenessof rFVIIa as a haemostatic agent, and we would like to report anexceptional thrombotic complication that we recently encoun-tered: a native non-calcified aortic valve thrombosis in a patienton ECMO support who received rFVIIa for massive bleedingafter coronary artery bypass grafting (CABG) surgery.A 60-year old male patient was admitted on an elective basisfor CABG surgery. His past medical history included hyperten-sion and multiple sclerosis. Coronary angiogram revealed triplevessel disease. Transthoracic echocardiography disclosed anormal aortic valve and an ejection fraction at 45%. The patienthad a normal hepatic and renal function and a normal coagu-lation profile before surgery. Cardiopulmonary bypass (CPB) wasestablished through median sternotomy. The obtuse marginalartery was not identified during surgery due to severe adherencebetween the lateral aspect of the left ventricle and the pericar-dium while the right coronary artery and the left anteriordescending artery were bypassed. Weaning from CPB wasunsuccessful, and femoro-femoral ECMO was instituted. Thepatient was transported to the angiography laboratory where adrug eluting stent was successfully implanted in the proximalcircumflex artery. Massive bleeding from the chest tube wasrecorded. Therefore, a 90-μg/kg of rFVIIa was infused, andbleeding decreased. Heparin infusion was commenced 18 hafter the surgery. On postoperative day (POD) 1, a transoesopha-geal echocardiogram (TEE) revealed severely depressed contrac-tility of the left ventricle and thrombus formation on the threecusps of the aortic valve on the aortic side. Despite full heparini-zation, a complete thrombosis of the aortic valve was disclosedon POD 3, and no clots were noted in the ECMO tubing. Hisfamily refused permission for further treatment and he diedafter the removal of the support.In view of our experience with this drug, we recommendcaution when rFVIIa is used in the postoperative period aftercardiac surgery in the setting of ECMO support; careful patientmanagement by routinely performing TEE and maintaininginotropic support for ventricular contractility and cusps mobilityis mandatory to prevent thrombus formation on the aorticcusps.REFERENCES[1] Chapman AJ, Blount AL, Davis AT, Hooker RL. Recombinant factor VIIa(NovoSeven RT) use in high risk cardiac surgery. Eur J Cardiothorac Surg2011;40:1314–9.[2] Magovern GJ Jr, Simpson KA. Extracorporeal membrane oxygenation foradult cardiac support: the Allegheny experience. Ann Thorac Surg 1999;68:655–61.[3] Rastan AJ, Dege A, Mohr M, Doll N, Falk V, Walther T et al. Early and lateoutcomes of 517 consecutive adult patients treated with extracorporealmembrane oxygenation for refractory postcardiotomy cardiogenic shock.J Thorac Cardiovasc Surg 2010;139:302–11.[4] Hacquard M, Durand M, Lecompte T, Boini S, Briançon S, Carteaux JP.Off-label use of recombinant activated factor VII in intractable haemor-rhage after cardiovascular surgery: an observational study of practices in23 French cardiac centres (2005–7). Eur J Cardiothorac Surg 2011;40:1320–7.European Journal of Cardio-Thoracic Surgery 42 (2012) 388–389 LETTER TO THE EDITORdoi:10.1093/ejcts/ezs109 Advance Access publication 10 May 2012The causes of re-operation in the Ross procedureSahin Bozoka,*, Mert Kestellib, Gokhan Ilhana and Banu Lafciba Department of Cardiovascular Surgery, Rize University Faculty of Medicine, Rize Training and Research Hospital, Rize, Turkeyb Department of Cardiovascular Surgery, Izmir Ataturk Training and Research Hospital, Izmir, Turkey* Corresponding author. Rize Egitim ve Arastırma Hastanesi, Kalp Damar Cerrahisi Klinigi, 53020 Rize, Turkey. Tel: +90-533-2362442; fax: +90-464-2170365;e-mail: sahinboz@yahoo.com (S. Bozok).Received 9 December 2011; accepted 3 February 2012Keywords: Ross procedure • Re-operation • Autograft • Aortic annulusWe congratulate our colleagues who have applied the Ross oper-ation thus far [1]. Despite the establishment of annular enlarge-ment, the presence of preoperative aortic regurgitation andautograft re-operation in the aortic stenosis group is said tolessen the need for aortic re-operation and a small-sized homo-graft leads to higher mortality rates.In the preoperative aortic regurgitation group, what could bethe reason for autograft re-operation? Is it a result of annularLetters to the Editor / European Journal of Cardio-Thoracic Surgery388Downloaded from https://academic.oup.com/ejcts/article/42/2/388/500883 by Rize University user on 27 February 2024stabilization or annular enlargement? We do not think the articleaddresses this situation.If factors such as left ventricular diameter, the angle betweenthe ascending aorta and interventricular septum, the size anddiameter of autografts, the change of body surface area, nativeaortic diameter and pressure gradient after distal anastomosishad been mentioned, we believe that important criteria wouldhave emerged.Reference[1] Alsoufi B, Manlhiot C, Fadel B, Al-Ahmadi M, Tamim M, McCrindle BWet al. The Ross procedure in children: preoperative haemodynamic mani-festation has significant effect on late autograft re-operation. Eur JCardiothorac Surg 2010;38:547–55.European Journal of Cardio-Thoracic Surgery 42 (2012) 389–390 LETTER TO THE EDITOR RESPONSEdoi:10.1093/ejcts/ezs110Reply to Bozok et al.Bahaaldin Alsoufi*King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia* Corresponding author. King Faisal Heart Institute (MBC 16), King Faisal Specialist Hospital and Research Center, PO Box 3354, Riyadh 11211 Saudi Arabia.Tel: +966-1-4647272 (ext 32049); fax: +966-1-4427791; e-mail: balsoufi@hotmail.com (B. Alsoufi).Received 25 January 2012; accepted 3 February 2012Keywords: Aortic valve replacement • Ross procedure • Rheumatic fever • Aortic regurgitation • Congenital heart diseaseWe thank Bozok and colleagues for their interest in our manu-script and appreciate their comments [1, 2]. The Ross procedureis a versatile operation that can be employed in patients withvarious congenital and acquired aortic valve disorders. It is con-sidered by many to be the aortic valve substitute of choice in smallchildren as it is associated with excellent haemodynamic andcardiac recovery; it offers potential for growth and does notrequire long-term anticoagulation. Therefore, early on in our, aswell as in others’, experience, it was widely utilized in variouschildren with different cardiac pathologies. The early expectationwas that autograft longevity would be better than that of anyavailable prosthesis. Unfortunately, early on we were faced with ahigh autograft failure rate in several subgroups of patients, whichled us to modify our selection criteria for the Ross procedure.We became aware that the Ross procedure can be done safelywith a low overall mortality risk of 3%. We noted that mortalitywas higher in younger children with congenital aortic stenosis,while we had zero mortality in our older patients with rheumaticaortic diseases, despite the frequent requirement for concomitantcardiac surgery at the time of the Ross procedure [1]. As smallerhomografts are employed in smaller children, we believe thatsmall homograft size is a surrogate for those other risk factorssuch as younger patients and congenital aortic stenosis. In ourcentre, mortality was particularly higher in neonates and younginfants with congenital aortic stenosis, especially those whorequired simultaneous mitral or arch procedures, and was relatedto those associated factors rather than the homograft itself.Annular enlargement was also frequently needed in ourpatients with congenital left ventricular outflow tract obstruction.When annular enlargement was needed, we used a modifiedRoss–Konno aorto-ventriculoplasty and we incised the aorticannulus into the septum and performed septal myectomywithout the need for a VSD patch insertion. This modified Ross–Konno technique has not been associated with an increased mor-tality risk. The concern was that patients who have undergone theRoss–Konno procedure may be at an especially high risk of auto-graft failure and re-operation due to the inherent disruption ofthe supporting aortic annulus, which may increase the subsequenthazard of annular and neo-aortic root dilatation and autograftregurgitation. We noted in our children who had the modifiedRoss–Konno procedure that the autograft continued to grow, butthat enlargement was not out of proportion to somatic growthand that the risk of autograft failure and subsequent re-operationwas not increased when annular enlargement was done.The vast majority of autograft re-operations in our series werein children who had preoperative aortic regurgitation, especially inpatients with a history of rheumatic fever, dilated aortic annulusand concomitant mitral valve disease [1]. In 27 children who hadthe autograft re-operation following the Ross procedure for rheu-matic aortic valve disease, the predominant pathologies causingregurgitation were annular dilatation with cusp prolapse andfailure of coaptation (n = 16), recurrence of inflammatory valvulo-pathy similar to that in rheumatic fever (n = 8), unknown (n = 2)and endocarditis (n = 1). There was a trend for a decreased auto-graft re-operation rate when annular stabilization was utilized. Ofnote, autograft failure in our patients with rheumatic aortic diseaseand preoperative regurgitation was noted mainly within the first 5years following the Ross procedure, which is different from themore delayed failure described in patients from Europe andNorthern America with predominant bicuspid aortic valve disease.It is noted that better patient selection and the multiple tech-nical modifications that we have adopted have mitigated theneed for autograft re-operation and we believe that our resultssupport the Ross procedure as the aortic valve replacement of LETTERSTOTHEEDITORLetters to the Editor / European Journal of Cardio-Thoracic Surgery 389Downloaded from https://academic.oup.com/ejcts/article/42/2/388/500883 by Rize University user on 27 February 2024

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The causes of re-operation in the ross procedure

The causes of re-operation in the ross procedure

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