Case. 15-year-old boy with bicuspid AV Severe AR with moderate AS. Ross vs. AVR (or AVP)
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1 Case 15-year-old boy with bicuspid AV Severe AR with moderate AS Ross vs. AVR (or AVP)
2 AMC case 14-year-old boy with bicuspid AV Severe AS with mild AR Body size Bwt: 55 kg, Ht: 154 cm, BSA: 1.53 m 2 Echocardiography AS: velocity 4 m/sec, Mild AR (II/IV) AV annulus: 20 mm, PV annulus: 21 mm Mild LVH
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4 Preoperative EKG
5 Surgical options Aortic valve repair 1) Definitive Treatment 2) Bridge procedure for later AVR Aortic valve replacement 1) Autograft PV (Ross procedure) 2) Bioprosthetic valve or homograft 3) Mechanical valve
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11 Figure 5. Freedom from reoperation after initial AVR stratified by prosthetic type. A multivariable equation was constructed for remaining alive after initial AVR without subsequent valve replacement according to the original competing risk model and forcing all valve types into the equation. The resulting model was then solved for a hypothetical 10- year-old patient of 40 kg undergoing operation in The autograft has superior longevity, whereas the tissue valves and allografts have considerably worse durability. The numbers in parentheses represent the total number of AVR episodes for each prosthesis type.
12 The Journal of Thoracic and Cardiovascular Surgery c February 2009
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16 Operative Details Detailed steps of the surgical intervention will not be discussed in this section; however, some important information will be briefly listed.4 Midline sternotomy was performed, and standard cardiopulmonary bypass and myocardial protection techniques were used in all cases. For AVR with a mechanical prosthesis, the valve was secured to the annulus with multiple mattressed sutures, with the pledgets placed at the ventricular aspect of the annulus. For the Ross procedure, the pulmonary autograft was implanted as a full root, with coronary transfer in all cases. The autograft muscle cuff was trimmed with sutures placed almost directly at the autograft annulus. The proximal suture line was performed with running polypropylene sutures. The neoaortic annulus was not reinforced in these patients, so as not to limit growth. In patients with left ventricular outflow tract (LVOT) obstruction, a modified Ross Konno technique was used. Part of the septum was cored out to completely open up the LVOT without creating a large ventricular septal defect. In those patients the fibrous annulus of the aortic valve was often divided, and the cut was partially taken down to the septum. In our current practice, in patients with a dilated aortic annulus of greater than 29 to 30 mm or with an aortic annulus 2 to 3 mm larger than the pulmonary valve annulus, the Ross procedure is not considered, and we rarely use any aortic annulus reduction techniques. The distal suture line was occasionally reinforced with Teflon felt in patients with a dilated ascending aorta. The immediate postoperative results were assessed in all patients in the operating room by means of transesophageal echocardiographic analysis.
17 AMC case 14-year-old boy with bicuspid AV Severe AS with mild AR Body size Bwt: 55 kg, Ht: 154 cm, BSA: 1.53 m 2 Echocardiography AS: velocity 4 m/sec, Mild AR (II/IV) AV annulus: 20 mm, PV annulus: 21 mm Mild LVH
18 Operation AVR with AV annulus enlargement 1) AV annular enlargement using bovine pericardium (Manougian) 2) AVR with Saint-Jude supra-annular Regent valve (21 mm)
19 Konno-Rastan Vouhe Nicks Manougian Nunez Courtesy of Dr. Park HK
20 Postoperative EKG
21 Echocardiographic findings Preoperative Postoperative (18m) LVOT velocity 4 m/sec 2.1 m/sec AR II / IV - MR trace trace TR trace trace LVIDd 48 mm 45 mm LVIDs 30 mm 20 mm LVEF 68 % 85 % LVDEV index 74 ml/m 2 56 ml/m 2 LV mass index 85 g/m 2 73 g/m 2
22 Case 15-year-old boy with bicuspid AV Severe AR with moderate AS AVR with mechanical valve
23 Pitfalls of each option Mechanical AVR Ross procedure
24 Pitfalls of each option Mechanical AVR Ross procedure Warfarin
25 Pitfalls of each option Mechanical AVR Ross procedure Warfarin
26 Pitfalls of each option Mechanical AVR Ross procedure No valve growth Warfarin
27 Pitfalls of each option Mechanical AVR Ross procedure No valve growth Warfarin
28 Pitfalls of each option Mechanical AVR Ross procedure No valve growth Warfarin Autograft dilatation
29 Pitfalls of each option Mechanical AVR Ross procedure No valve growth Autograft dilatation Warfarin
30 Pitfalls of each option Mechanical AVR Ross procedure No valve growth Warfarin Neo AR Autograft dilatation
31 Pitfalls of each option Mechanical AVR Ross procedure No valve growth Warfarin Neo AR Autograft dilatation
32 Pitfalls of each option Mechanical AVR No valve growth Warfarin Ross procedure RV-PA conduit Neo AR Autograft dilatation
33 Pitfalls of each option Mechanical AVR No valve growth Warfarin Ross Loss procedure RV-PA conduit Neo AR Autograft dilatation
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