reoperation after previous ross procedure1994-2010 sts database 648,541 avr 3,054 (0.47%) ross...
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Reoperation after previous Ross procedure
Victor Tsang
Society of Thoracic Surgeons of Thailand2016
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As a living autograft, the transplanted pulmonary valve
has the prospect of long term or permanent survival .
Ross, Lancet 1967
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Ross operation Not often enough in clinical practice ?
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1994-2010STS database648,541 AVR
3,054 (0.47%) RossRecent annual incidence < 0.1%
Brett Reece et al. Rethinking the Ross procedure in Adults. ATS 2014
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Outcome and Reinterventionstudies
Centre experience and expertise influence long term
results Charitos et al JTCVS 2012
Sievers et al. JTCVS 2010
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A living valve implanted in the aortic position can significantly improve the
long term outcomes in patients
Yacoub, Lancet 2010
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Better quality of life following pulmonary
autografts compared with mechanical valves
• Aicher et al JTCVS 2011
• Notzold et al JACC 2001
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To achieve a ‘living’ aortic valve with no
anticoagulation and a good long term
outcome
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Inclusion cylinder method for aortic valve replacement utilising the Ross operation in adults with
predominant aortic stenosis – 99 % freedom from reoperation on the
aortic valve at 15 years
Skillington et al. Glob Cardiol Sci Pract 2013
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Markus Liebrich et al., ATS 2014
1997-2012
630 patients
Mean follow-up 8.3 +/- 4.6 yrs
49 reoperations11 early38 late
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Early reoperations (n=11)
Valve replacement (8)
• Endocarditis
Valve repair (3)
• Rupture of the proximal suture line• Development of psuedo aneurysm• Covered rupture of proximal autograft
Markus Liebrich et al., ATS 2014
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Late reoperations (n=38)15 without
dilatation of neo-aortic sinus15 valve replacement
20 with
dilatation of neo-aortic sinus16 valve sparing repair4 Bentall / valve replacement
Markus Liebrich et al., ATS 2014
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David
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RossTiming and technique of
surgery in the young
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• Previous BAV• Previous surgical valvuloplasty
The majority of young patients at Ross
have mixed aortic valve disease
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When should it be done in terms of LVEDV recovery?
Cheung et al., Cardiol Young, 2003
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Cardiopulmonary exercise testing
Mean exercise capacity 87% +/- 22% of
predicted
Puranik, Tsang et al. Heart 2010
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• Borderline LV volume
• Critical aortic stenosis
• Arch hypoplasia
• Smallish mitral valve
Benefits the very young
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Sara K. Pasquali et al., JACC 2007
GOSH :
Annulus = 0.31 (range -2.9 to 3.2)Sinus = 2.7 (range -3.1 to 5.4)STJ = 3.1 (range -1.2 to 6.0)
Annulus = 3 to 4Sinus = 7 to7.5STJ = 4 to 5
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Sara K. Pasquali et al., JACC 2007
GOSH :
Annulus 0.14/y (95% CI 0.32 - 0.59) Annulus = 0.31/y
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Ross at GOSH
75 childrenAge 10.2 yrs (range 0.44-18 years)Follow-up 5.2 yrs (up to 13.2 years)
5 reoperations3 autograft re-intervention2 LVOT re-intervention
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Autograft reintervention
Case No.
Age at Ross
Time toreop
Indication/pathology
Operation Result
1 15.2 years 50 days RegurgitationDehiscence of the non
coronary cusp, and suspected endocarditis
Repair Good valvular function
2 10.2 years 6.7 years RegurgitationPseudoaneurysm
Dehiscence of posterior aspect of autograft
Repair Good valvular function
3 12.0 years 5.4 years RegurgitationPerforation of left
coronary cusp at time of Ross
Repair Good valvularfunction
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LVOT reintervention
Case No.
Age at Ross
Time toreop
Indication/pathology
Operation Result
111
months1.8 years Stenosis. Borderline
LVOT with an favourable angulation
at time of Ross
Resection 6 years after reoperation:
v-max 3.6 m/s
2 1.8years
10.1 years Development of subvalar membrane
Resection 2.5 yrs after reoperation:v-max 3 m/s
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Use of cine CT images to characterise tissue
Calculate strain and distensibility
0 0.2 0.4 0.6 0.8 1
40
42
44
46
48
50
Din
Dout
0% cardiac cycle
10% cardiac cycle
Dia
me
ter
[mm
]
Time [s]
Plot temporal variation
𝐷𝑖𝑠𝑡𝑒𝑛𝑠𝑖𝑏𝑖𝑙𝑖𝑡𝑦 =(𝐴𝑠𝑦𝑠𝑡 − 𝐴𝑑𝑖𝑎𝑠)
𝐴𝑑𝑖𝑎𝑠(𝑃𝑠𝑦𝑠𝑡 − 𝑃𝑑𝑖𝑎𝑠)
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Dilated autograft vs normal
0
20
40
60 Autograft
Control
Strain [%] Distensibility[MPa-1]
p = 0.21
p = 0.46
n = 11in each group(age-matched)
Dilated autografts (>45 mm) after the Ross procedure are bigger than normal but maintains mechanical property, unlike aneurysmal tissue which is much stiffer.
Dilated autografts may need to be treated differently from
dilated native aorta.
Torii, Yacoub, et al. QFARF 2012.
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2 patients from the original Lancet
series by Donald Ross operated
in 1967 in London
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Patient 1 Patient 2
Age at Ross op in 1967 32 yrs 21 yrs
Surgeons D Ross D Ross / M Yacoub
Ethiology Congenital aortic valve incompetence
Endocarditis (susp. bicuspid valve)
Surgical technique Subcoronary Subcoronary
Time to valve explantpost-Ross
42 yrs (moderate autograftstenosis and obstructed homograft -> autograftrepair, homograft replacement and CABGx4 , 2006, sudden death 2009)
44 yrs (mixed autograftdisease with dorminantregurgitation, impaired LV, and dilated aorta → Bentall, 2011)
Histology Trilaminar structureThickened aortic valve cuspsNormal coaptationSatisfactory cusp mobility Endothelial cells observed on both sides of cusps
Trilaminar structureAortic cusps showed calcification and degenerationSenile calcific aortic stenosis present
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Explanted autograft 42 years old
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Immuno-histological studies
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ObservationsThe Ross procedure can offer 40 or
more years of warfarin free survival.
The viability of the autograft as a functional unit is proven at 10 or more years in younger age group.
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What remains to be proven in the young population ?
Would the adapted neoaorta in a root replacement reach a steady state to function as a longer term (>20 years) stable aortic valve unit
?
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Thank you
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Histochemical studies
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Histology
• Preserved very long-term viability of the autograftvalve after the Ross procedure (42 and 44 years)
• Illustrates the capacity of pulmonary autograftvalves to adapt to their new biomechanical environment
• Preserved cellularity, particularly endothelial integrity, is a major factor in the resistance of pulmonary autografts to infection, calcification and other valve-related complications
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RVOT reintervention
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The Paediatric Rosslate outcomes
1) Surgical technique
2) Patient factors
3) Histology
4) Bioengineering perspective
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Patient factors
• Young age
• Bicuspid aortic valve
• Preoperative AI with dilated aortic
annulus is a marker for future
dilation
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Rheumatic valves
• Ross procedure confers survival advantages
over mechanical valve in young patients with
rheumatic aortic valve disease
• Impaired autograft durability in younger
patients (<30 years) with rheumatic aortic
regurgitation and concomitant MR
Raja et al. Interactive Cardiovascular and Thoracic Surgery 2010
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GOSH2000 – 201185 Ross op
(1 neonate and 7 infants)
1 late death (PHT)
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Patient factorsSurvival of neonates with
critical aortic stenosis
• An expanding surgical cohort of survivors
with restrictive left ventricle / EFE and
persistent pulmonary hypertension
Burch et al Heart 2004
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The Paediatric Rosslate outcomes
1) Surgical technique
2) Patient factors
3) Histology
4) Bioengineering perspective
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Histology(3-6 years post Ross)
• Explanted autografts are viable and have
a near-normal trilaminar cuspal structure
and collagen architecture
• Autograft walls show focal loss of normal
smooth muscle cells, elastin, and collagen
Rabkin-Aikawa et al. J Thorac Cardiovasc Surg. 2004
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Patient 2 (44 yr post Ross)
Autograft regurgitation Homograft stenosis
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The Paediatric Rosslate outcomes
1) Concept and surgical technique
2) Patient factors
3) Histology
4) Bioengineering perspective
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When to do Ross 1. Often enough
in clinical practice ? 2. Timing of surgery
in the young ?
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Quadricuspid neoaortic valve
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Insights from 40 years follow-up of a patient with the Ross Procedure
Showing
Autograft Valve
Regurgitation
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Showing
Homograft
Stenosis
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Figure 1 Histological section showing the triple layer architecture of a normal aortic valve. Endothelial cells form a monolayer on each side of the cusp. Interstitial cells, a mix of fibroblasts, smooth muscle cells (SMCs) and myofibroblasts fil...
Ismail El-Hamamsy , Adrian H. Chester , Magdi H. Yacoub
Cellular regulation of the structure and function of aortic valves
Journal of Advanced Research Volume 1, Issue 1 2010 5 - 12
http://dx.doi.org/10.1016/j.jare.2010.02.007
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1. Proximal suture line (close interrupted sutures) anchored within the fibromuscular LVOT for support
2. Outflow anastomosisshould not exceed the autograft diameter
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Ross Procedure 1967
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Bicuspid aortic valve