Transcript Aortic Root Dilatation S/P Ross Procedure

Aortic Root Dilatation S/P
Ross Procedure
Michael Rechitsky, MD
History
• 13 y/o male who initially presented for
evaluation of progressive dilatation of
aortic root after Ross procedure.
MRI
Moderately dilated aortic root, measuring up to 42 mm.
Diagnosis
• Aortic Root Dilatation S/P Ross procedure.
Flow quantitation also demonstrated Aortic
Valve Regurgitation
DDx
• Marfan's vs other connective tissue
disorders
• Aortic Regurgitation
• Associated with Bicuspid Aortic Valves
• Mycotic Aneurisms
Discussion
• Options for Aortic Valve Surgery
• 1. Aortic valve repair (or balloon valvuloplasty for stenosis)
• 2. Aortic valve replacement
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- Mechanical valve
- Bioprosthetic valve
- Homograph valve
- Ross procedure
Ross Procedure (also called Switch Procedure)
younger than 40 to 50, avoid anticoagulation
Involves replacing diseased AV with PV. PV is replaced with allograft
retrospective review of 301 pt's demonstrated survival and quality of
life were significantly better than with other pocedures.
Also: 13% vs 45% reoperation at 9 yrs.
• Advantages: The pulmonic valve is anatomically very similar to
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aortic and it will grow as the child or adolescent grows.
The blood flows with less pressure through the pulmonary valve
than the aortic valve, therefore a homograft valve could last longer
in PV, and more tolerated even if fails
risk of thromboembolic infection is very low, lower than for any
alternative valve prosthesis.
hemodynamic performance makes the Ross operation an attractive
alternative for athletes.
The pulmonary autograft valve has a good chance of being a lifelasting solution for the aortic valve.
Drawbacks: technically difficult and long surgery, as it requires two
valve replacements, hence also potential to convert 1 diseased valve
into 2. Only recommended for young patients who would tolerate a
longer bypass time
The valve cusps are strong enough to withstand the systemic
pressure, but the pulmonary artery wall does dilate when exposed
to systemic pressure, occasionally enough to cause the autograft
valve to leak.
The risk of requiring re-operation for a leaking autograft valve is
about 10 percent within 10 years after the operation.
• Aortic valve repair
• Advantages: natural anatomy is preserved, no anticoagulation
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Drawbacks: technically difficult, not an option for stenotic valves, 20
to 25 percent of patients will require a valve replacement within ten
years.
Aortic valve replacement
1. Mechanical Valve Replacement
Advantages: sturdy, designed to last a lifetime
Drawbacks: anitcoaglation
2. Bioprosthetic valve replacement
made of tissue, but also have some artificial components
Advantages: No Anitcoag
Drawbacks: 50 percent chance of lasting 15 years or longer due to
accelarated calcification and degeneration
3. Allograft valve replacement
Advantages: best and safest option for patients with severe disease,
natural anatomy is preserved or restored, and patients do not need
to take any blood-thinner medications after surgery.
Drawbacks: limited availability, technically difficult.
expected to last about 15 to 20 years due to accelarated
calcification and degeneration. Like bioprosthetic valves, homografts
are not as durable in younger patients.
References
• Mavroudis, C (2003). Pediatric Cardiac
Surgery. Philadelphia, Mosby.
• Pettersson, G. Aortic Valve Surgery in The
Young Adult Patient