Aortic Root Dilatation S/P Aortic Root Dilatation S/P Ross ProcedureRoss Procedure

Michael Rechitsky, MDMichael Rechitsky, MD

HistoryHistory

• 13 y/o male who initially presented 13 y/o male who initially presented for evaluation of progressive for evaluation of progressive dilatation of aortic root after Ross dilatation of aortic root after Ross procedure. procedure.

MRIMRI

Moderately dilated aortic root, measuring up to 42 mm.

DiagnosisDiagnosis

• Aortic Root Dilatation S/P Ross Aortic Root Dilatation S/P Ross procedure. Flow quantitation also procedure. Flow quantitation also demonstrated Aortic Valve demonstrated Aortic Valve Regurgitation Regurgitation

DDxDDx

• Marfan's vs other connective tissue Marfan's vs other connective tissue disorders disorders

• Aortic Regurgitation Aortic Regurgitation

• Associated with Bicuspid Aortic Associated with Bicuspid Aortic ValvesValves

• Mycotic AneurismsMycotic Aneurisms

DiscussionDiscussion

• Options for Aortic Valve Surgery Options for Aortic Valve Surgery

• 1. Aortic valve repair (or balloon valvuloplasty for stenosis) 1. Aortic valve repair (or balloon valvuloplasty for stenosis) • 2. Aortic valve replacement 2. Aortic valve replacement

- Mechanical valve - Mechanical valve - Bioprosthetic valve - Bioprosthetic valve - Homograph valve - Homograph valve - Ross procedure - Ross procedure

• Ross ProcedureRoss Procedure (also called Switch Procedure) (also called Switch Procedure) • younger than 40 to 50, avoid anticoagulation younger than 40 to 50, avoid anticoagulation • Involves replacing diseased AV with PV. PV is replaced with Involves replacing diseased AV with PV. PV is replaced with

allograft allograft • retrospective review of 301 pt's demonstrated survival and retrospective review of 301 pt's demonstrated survival and

quality of life were significantly better than with other pocedures. quality of life were significantly better than with other pocedures. • Also: 13% vs 45% reoperation at 9 yrs. Also: 13% vs 45% reoperation at 9 yrs.

• Advantages: The pulmonic valve is anatomically very similar to aortic and it Advantages: The pulmonic valve is anatomically very similar to aortic and it will grow as the child or adolescent grows. will grow as the child or adolescent grows.

• The blood flows with less pressure through the pulmonary valve than the 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 aortic valve, therefore a homograft valve could last longer in PV, and more tolerated even if fails tolerated even if fails

• risk of thromboembolic infection is very low, lower than for any alternative risk of thromboembolic infection is very low, lower than for any alternative valve prosthesis. valve prosthesis.

• hemodynamic performance makes the Ross operation an attractive hemodynamic performance makes the Ross operation an attractive alternative for athletes. alternative for athletes.

• The pulmonary autograft valve has a good chance of being a life-lasting The pulmonary autograft valve has a good chance of being a life-lasting solution for the aortic valve. solution for the aortic valve.

• Drawbacks: technically difficult and long surgery, as it requires two valve Drawbacks: technically difficult and long surgery, as it requires two valve replacements, hence also potential to convert 1 diseased valve into 2. Only replacements, hence also potential to convert 1 diseased valve into 2. Only recommended for young patients who would tolerate a longer bypass time recommended for young patients who would tolerate a longer bypass time

• The valve cusps are strong enough to withstand the systemic pressure, but The valve cusps are strong enough to withstand the systemic pressure, but the pulmonary artery wall does dilate when exposed to systemic pressure, the pulmonary artery wall does dilate when exposed to systemic pressure, occasionally enough to cause the autograft valve to leak. occasionally enough to cause the autograft valve to leak.

• The risk of requiring re-operation for a leaking autograft valve is about 10 The risk of requiring re-operation for a leaking autograft valve is about 10 percent within 10 years after the operation. percent within 10 years after the operation.

• Aortic valve repair Aortic valve repair • Advantages: natural anatomy is preserved, no anticoagulation Drawbacks: technically Advantages: natural anatomy is preserved, no anticoagulation Drawbacks: technically

difficult, not an option for stenotic valves, 20 to 25 percent of patients will require a difficult, not an option for stenotic valves, 20 to 25 percent of patients will require a valve replacement within ten years. valve replacement within ten years.

• Aortic valve replacementAortic valve replacement 1. Mechanical Valve Replacement 1. Mechanical Valve Replacement • Advantages: sturdy, designed to last a lifetime Advantages: sturdy, designed to last a lifetime • Drawbacks: anitcoaglation Drawbacks: anitcoaglation 2. Bioprosthetic valve replacement2. Bioprosthetic valve replacement • made of tissue, but also have some artificial componentsmade of tissue, but also have some artificial components• Advantages: No Anitcoag Advantages: No Anitcoag • Drawbacks: 50 percent chance of lasting 15 years or longer due to accelarated Drawbacks: 50 percent chance of lasting 15 years or longer due to accelarated

calcification and degeneration calcification and degeneration 3. Allograft valve replacement3. Allograft valve replacement • Advantages: best and safest option for patients with severe disease, natural anatomy 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 is preserved or restored, and patients do not need to take any blood-thinner medications after surgery. medications after surgery.

• Drawbacks: limited availability, technically difficult. Drawbacks: limited availability, technically difficult. • expected to last about 15 to 20 years due to accelarated calcification and expected to last about 15 to 20 years due to accelarated calcification and

degeneration. Like bioprosthetic valves, homografts are not as durable in younger degeneration. Like bioprosthetic valves, homografts are not as durable in younger patients. patients.

ReferencesReferences

• Mavroudis, C (2003). Pediatric Mavroudis, C (2003). Pediatric Cardiac Surgery. Philadelphia, Cardiac Surgery. Philadelphia, Mosby. Mosby.

• Pettersson, G. Aortic Valve Surgery in Pettersson, G. Aortic Valve Surgery in The Young Adult Patient The Young Adult Patient