Mid-term Outcome of 100 Consecutive Ross Procedures: Excellent Survival, But Yet to Be a Cure.

The Ross procedure offers excellent short-term outcome but the long-term durability is under debate. Reinterventions and follow-up of 100 consecutive patients undergoing Ross Procedure at our centre (1993-2011) were analysed. Follow-up was available for 96 patients (97%) with a median duration of 5.3 (0.1-17.1) years. Median age of the patient cohort was 15.2 (0.04-58.4) years with 76 males. 93% had underlying congenital aortic stenosis. Root replacement technique was applied in all. The most common valved conduits used for reconstruction of the right ventricular outflow tract were homografts (66 patients) and bovine jugular vein (ContegraR) graft (31 patients). Additional procedures included Ross-Konno procedure (14%), resection of subaortic stenosis/myectomy (11%) and reduction plasty of the ascending aorta (25%). One patient died within the first 30 days (1%). Late deaths occurred in 4 patients (4%) 0.5-4.5 years postoperatively: causes included pulmonary hypertension due to endocardial fibroelastosis (2), subarachnoid haemorrhage (1) and sudden cardiac death (1). Five-year survival was 93.6 (95% CI 88.1-99.1)%. Moderate or severe aortic (autograft) regurgitation needing reoperation occurred in 8 patients with a 5-year freedom from autograft reoperation of 98.5 (95.6-100)%. Five-year freedom from reintervention (surgery or catheter based) on the right ventricular outflow tract conduit was 91.5 (85.5-96.5)%. Univariate predictors of this reinterventions were smaller graft size (p = 0.03) and use of a ContegraR graft (p = 0.04). Ross procedure can be performed with low mortality and good survival in the long term. Most of the reinterventions are related to the neo-right ventricular outflow tract and may be partly attributed to the lack of growth. While the Ross Procedure remains an invaluable option for aortic valve disease in children, new solutions for the neo-pulmonary valve as well as for the less often occurring problems on the autograft are needed.

Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.

OBJECTIVE: We evaluated the mid-term results of the right axillary incision used for the repair of various congenital heart defects. METHODS: All the patients who were operated with this incision between March 2001 and December 2007 were reviewed. There were 123 patients (median age 4.7 {0.4-19.4} years and median weight 16.6 {3.8-62} kg) undergoing atrial septal defect (ASD) closure (62), repair of partial anomalous pulmonary venous connection (PAPVC) (22), correction of partial atrioventricular septal defect (AVSD) (19), and restrictive perimembranous ventricular septal defect (VSD) (20). Additional procedures involved tricuspid valve plasty (10), mitral annuloplasty (3), reduction plasty of the aortic sinus (2), resuspension of the aortic valve cusp (2), sub aortic membrane resection (1), or reimplantation of Scimitar vein (1). The surgical technique involved peripheral (groin) and central (SVC+/-aorta) cannulation for institution of cardiopulmonary bypass. Fibrillatory arrest was used for repair of ASDs and cardioplegic arrest for repairs involving the atrioventricular valves as well as VSDs. The median CPB and aortic clamp times were 72 (35-232) and 0 (0-126) min, respectively. RESULTS: There was no need for conversion to another approach in any patient. Early morbidity included transient paresis of left upper arm (1), stenting of SVC after repair of a sinus venosus defect (1) and revision for bleeding (1). Follow-up echo showed no residual defect in 116 patients and minor residual defects in 7 patients: tiny ASD (2), tiny VSD (1) and mitral regurgitation (4). One patient developed stenosis in the right external iliac artery used for cannulation, necessitating surgical intervention. All the patients are in excellent condition after a median follow-up of 4.1 (0.4-7.1) years. The incision healed well and the thorax and the breast showed no deformity on follow-up. CONCLUSIONS: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because of its deceitful location, and the camouflaging effect of being hidden by the resting arm, it has superior cosmetic appeal compared to conventional incisions. The incision does not interfere with subsequent development of the thorax or the breast (in case of females).

Muscle-sparing extrapleural approach for the repair of aortic coarctation.

BACKGROUND: This paper describes a muscle-sparing, extrapleural approach to repair aortic coarctation, and evaluates the results with established standards. METHODS: Forty consecutive patients with aortic coarctation (median age, 8 days; weight, 3.3 kg) were approached with a less invasive technique consisting of a short posterior thoracotomy, with only minimal (24 patients) or no (16 patients) division of thoracic wall muscles and a subperiosteal-extrapleural approach. Extended resection of the coarctation with enlargement of the distal aortic arch was performed in all patients. The median cross-clamp and operative times were 22 and 90 minutes, respectively. RESULTS: The repair was possible in all patients without needing conversion. There was no intraoperative or postoperative related complication. Two patients died early of low cardiac output as a result of ventricular fibroelastosis and respiratory failure. One patient died late of unrelated cause. The perioperative mean gradients across the neoarch were less than 5 mm Hg in all but 3 patients with proximal (2 patients) or mid arch (1) stenosis. The median ventilation time, intensive care unit stay, and hospital stay in isolated coarctation repairs was 2, 4.5, and 11 days, respectively. One patient had a recurrent stenosis at the site of surgical repair. Two patients underwent successful balloon dilatation, and 2 had surgical enlargement plasty of the proximal aortic arch at the time of intracardiac repair. None of the patients required chronic antihypertensive medication. At 29 months, freedom from reintervention on the isthmus and arch plus isthmus was 97.1% and 89.7%, respectively. CONCLUSIONS: A muscle-sparing, extrapleural approach for the repair of aortic coarctation is possible and provides results similar to conventional techniques. The approach reduces postoperative morbidity related to division of thoracic wall muscles and handling of the lung, restores a normal intercostal space, and produces superior cosmetic results, while at the same time leading to early and permanent relief of proximal hypertension.

Early insertion of a pulmonary valve for chronic regurgitation helps restoration of ventricular dimensions.

BACKGROUND: This study assesses the results of early insertion of a pulmonary valve for chronic pulmonary regurgitation based on right ventricular volume measurements. METHODS: Valved conduits were prospectively inserted in 39 patients (aged 14 to 39 years) when the right ventricular (RV) end-diastolic volume index on magnetic resonance imaging (MRI) exceeded 150 mL/m2. Changes in morphology and function of the RV were prospectively analyzed by an MRI at 6 months postoperatively (available in 21 patients). RESULTS: There were no early or late deaths. All conduits showed good function at a median 15 month follow-up. Postoperative RV end-systolic and end-diastolic volumes showed a significant positive correlation (p = 0.005 and p < 0.0001), while postoperative left ventricular (LV) ejection fraction showed a significant negative correlation (p = 0.03) with preoperative RV end-diastolic volume index. Seven patients who achieved normal RV end-diastolic volume index (< or = 100 mL/m2) (group 1) when compared with 14 remaining patients (group 2) showed that they differed significantly with respect to their preoperative RV end-diastolic volume index (170.3 +/- 21.1 vs 203.6 +/- 35.6; p = 0.02) and postoperative LV ejection fraction (59.9 +/- 4.2 vs 54 +/- 7%, p = 0.03). CONCLUSIONS: Our results show that the improvement in ventricular dimensions and functions directly correlates with the timing of pulmonary valve insertion. Early insertion leads to normalization and late insertion leads only to improvement. These observations, along with a low morbidity for these reoperations, justify earlier reintervention in cases of chronic pulmonary regurgitation. A RV end-diastolic volume index of 150 mL/m2 seems to be a practical cutoff value to prescribe pulmonary valve insertion.