Cardiopulmonary Research Science and Technology Institute and Medical City Dallas Hospital, Dallas, Texas

Transcription

1 Redo Autograft Operations After the Ross Procedure ADULT CARDIAC William T. Brinkman, MD, Morley A. Herbert, PhD, Syma L. Prince, RN, Connor Ryan, BA, and William H. Ryan, MD Cardiopulmonary Research Science and Technology Institute and Medical City Dallas Hospital, Dallas, Texas Background. Autograft dilatation after the Ross procedure is the most common cause of late autograft failure. We looked at results after reoperation for autograft dysfunction using autograft sparing and composite root replacement techniques. Methods. Data were abstracted from our prospectively collected Ross registry for 160 consecutive patients who underwent a Ross procedure by a single surgeon between 1994 and Follow-up records were obtained, and the last echocardiographic report after reoperation was analyzed. Results. Autograft reoperation was necessary in 17 patients, at a median interval of 6.9 years after the original procedure. Indications for reoperation were insufficiency with autograft dilatation in 16 patients, and without dilatation in 1 patient. Surgical procedures used at reoperation included autograft reimplantation in 6 patients (35.3%), autograft remodeling procedure in 1 patient (5.9%), composite root replacement with mechanical valved conduit in 5 patients (29.4%), composite root replacement with biologic valved conduit in 3 patients (17.6%), and mechanical aortic valve replacement in 2 patients (11.8%). At a median follow-up of 5.0 years after reoperation, freedom from greater than 2 aortic insufficiency was 100% (17 of 17 patients) in both reimplantation and replacement groups. There was 1 death after reoperation (at >14 years) related to complications from systemic lupus erythematosus. There have been no strokes after autograft reimplantation. Conclusions. Autograft valve reimplantation and composite aortic root replacement are effective treatments for aortic root dilatation and aortic insufficiency after the Ross procedure. Echocardiographic follow-up demonstrates reasonable short-term function after autograft preservation procedures. (Ann Thorac Surg 2012;93: ) 2012 by The Society of Thoracic Surgeons The Ross Procedure is associated with excellent longterm survival in adult patients and avoids the longterm risk of anticoagulation with mechanical valves [1 3]. Autograft dilation with or without aortic insufficiency emerges in a significant number of patients during follow-up, however. It is unclear which subset of Ross patients will ultimately experience autograft insufficiency, and it is uncertain which operative techniques may prevent this complication. In a significant number of Ross failures, the dilated autograft root results in a trileaflet insufficient aortic valve amenable to remodeling and reimplantation techniques described by Yacoub and colleagues [4] and David and associates [5] for aortic root aneurysms. Excellent short-term results with these techniques have encouraged us to use this strategy whenever feasible in redo Ross operations. In the absence of leaflet prolapse or leaflet damage, autograft preservation techniques should yield comparable results with Accepted for publication Jan 31, Presented at the Fifty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9 12, Address correspondence to Dr Brinkman, Cardiopulmonary Research Science and Technology Institute, 7777 Forest Ln, C-742, Dallas, TX 75230; willibri@baylorhealth.edu. those in de novo aortic root aneurysms. We examined our short-term results with autograft operations and particularly that subset of patients who received autograft reimplantation. Patients and Methods Patient Population From 1994 to December of 2008, 160 patients underwent the Ross procedure by a single surgeon (W.H.R.). Of these patients, 17 (10.6%) underwent reoperation after the Ross procedure by 2 surgeons (W.H.R., W.T.B.). This study was approved by the North Texas Institutional Review Board at Medical City in Dallas with exempt status (waiver of consent). The authors Society of Thoracic Surgeons certified, audited database was queried for all patients undergoing a Ross procedure by the senior author (W.H.R.). Statistical Analysis Data were collected from our audited Society of Thoracic Surgeons database and combined with follow-up data obtained from the surgeon s office notes or from cardiologists following the patients after their Ross procedure. Data analysis was carried out with SAS 9.2 (SAS Institute, Cary, NC) with categorical variables 2012 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 ADULT CARDIAC 1478 BRINKMAN ET AL Ann Thorac Surg REDO AUTOGRAFT OPERATIONS AFTER ROSS 2012;93: analyzed using 2 or Fisher s exact test and continuous variables subjected to Student s t tests. Cumulative hazard curves were calculated using the semiparametric Cox proportional model. Surgical Technique The Ross procedure was performed in all cases as a freestanding root with all excess pulmonary artery trimmed to the pulmonary sinotubular junction (STJ). The aortic annulus was sized appropriate for body surface area. When necessary to match the autograft annulus, a circumferential aortic annuloplasty of 3-0 Prolene (Ethicon, Somerville, NJ) was performed. The annular suture line was made up of 4 0 Prolene (Ethicon) interrupted sutures tied over a double-layer pericardial buttress. The neo-stj was sized to the autograft STJ and reinforced with a double-layer pericardial buttress. When there was an aortic autograft mismatch, or when the aorta was 4 cm or greater, an interposition graft (Hemashield Platinum Woven Double Velour Vascular Graft; Maquet Cardiovascular, Wayne, NJ) was used. All patients were treated with -blockers for at least 1 year postoperatively. Technique for reoperation was dependent primarily on the status of the autograft cusps. If the cusps were found to be prolapsing or damaged significantly, autograft preservation was not attempted. Once autograft preservation was ruled out, we then proceeded with aortic root replacement as clinically indicated and according to patient preference of mechanical or biologic valve. Our primary technique for autograft preservation was reimplantation as described by David and colleagues [5, 6]. However, in cases of single autograft sinus dilatation, we then used the remodeling technique of Yacoub and coworkers [4] to replace the affected sinus. Follow-Up These patients have been followed with scheduled clinical evaluations and echocardiograms, and their outcomes have been previously reported by us [1]. This paper reports on the midterm outcomes of those patients undergoing reoperation during that period and those who have had reoperation since that reporting period. Criteria for reoperation included progressive aortic insufficiency defined by standard echocardiographic criteria with symptoms or patients with increasing left ventricular size or patients with left ventricular end-diastolic dimensions greater than 6.5 cm without symptoms. In addition, patients whose autograft root dimensions were greater than 5 cm with or without aortic insufficiency underwent reoperation. Echocardiogram Technique Aortic regurgitation was assessed in accordance with the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, in cooperation with the Society of Cardiovascular Anesthesiologists, the Society for Cardiovascular Angiography Interventions, and the Society of Thoracic Surgeons [7] by multiple techniques using a parasternal long-axis and apical four-chamber view. Continuous Doppler was used to determine deceleration slope and pressure half-time of regurgitant jets. Aortic insufficiency was graded using standardized values in the majority of examinations, with the severity of regurgitation reported on a scale of 0 to 4 [8]. All preoperative and postoperative transthoracic echocardiograms were reviewed and adjudicated by the primary investigator (W.H.R.). Many of the echocardiograms used for these data were performed outside of our tertiary referral center. Instances of inadequate echocardiography data were decided by the primary investigator (W.H.R.) and were repeated in our institution. Results The original series of patients consisted of 160 patients who had a Ross procedure, with 58.1% (93 patients) being operated on for a diagnosis of aortic insufficiency (AI), whereas 41.9% (67 patients) were operated on with a diagnosis of aortic stenosis. These patients have been followed for a mean time of years (median, 10.3 years; range, 3.3 to 16.9 years). During that time 17 have had reoperations for recurrent insufficiency of the autograft. There were no instances of autograft stenosis. Sixteen of the 17 redo patients had their first procedure for treatment of AI. Autograft Reoperation Indications for reintervention on the 17 patients with autograft dysfunction included autograft insufficiency ( 2 ) without autograft dilatation (5.9%; 1 of 17 patients), autograft insufficiency with autograft dilatation (88.2%; 15 of 17 patients), and autograft dilatation without autograft insufficiency (5.9%; 1 of 17 patients). Mean time to reoperation was years (median, 6.9 years; range, 1.4 to 14.5 years). Surgical procedures used at reoperation included autograft reimplantation in 6 patients (35.3%), autograft remodeling procedure in 1 patient (5.9%), composite root replacement with mechanical valved conduit in 5 patients (29.4%), composite root replacement with biologic valved conduit in 3 patients (17.6%), and mechanical aortic valve replacement in 2 patients (11.8%). Malfunction of the right ventricular outflow tract homograft was addressed in 2 patients (1 patient with severe pulmonic stenosis related to systemic lupus erythematosus, 1 with severe pulmonary insufficiency owing to endocarditis). Cusp repair techniques were not used in any patient undergoing autograft preservation. The reoperations have been categorized as an autograft preserving or replacement procedure. The preoperative characteristics of the patients are shown in Table 1. Postoperative complications after redo surgery were minimal as shown in Table 2. Both types of procedures were equivalent, although the autograft preservation cases had longer cross-clamp and perfusion times.

3 Ann Thorac Surg BRINKMAN ET AL 2012;93: REDO AUTOGRAFT OPERATIONS AFTER ROSS Table 1. Characteristics of Reoperation Patients Before Redo Procedure Patient Characteristic Autograft Preservation (n 7) Replacement (n 10) p Value Age at redo (y) (median, 41) (median, 46) Time after initial Ross (y) (median, 8.6; range, ) (median, 6.1; range, ) EF Males 71.4% (5/7) 60.0% (6/10) Infectious endocarditis 14.3% (1) 10.0% (1) Severe aortic 71.4% (5/7) 90.0% (9/10) regurgitation Aortic stenosis 0 0 NA Autograft dilatation 100% (7/7) 90.0% (9/10) Original diagnosis of AI 100% (7/7) 100.0% (10/10) ADULT CARDIAC AI aortic insufficiency; EF ejection fraction; NA not applicable. There were also no cases of operative mortality, deep sternal wound infection, permanent stroke, reoperation for bleeding, reoperation for valve problems, postoperative renal failure requiring dialysis, or any other complication. Significantly more AI patients required reoperation starting at an earlier time, leading to increased overall hazard for the AI patients. The AI to aortic stenosis hazard ratio was 6.6, although with a small number of events, it failed to reach statistical significance (p 0.069; Fig 1). In the reoperation patients, there has been 1 death 14 years after reoperation in a patient with a mechanical aortic valve. Her death was owing to complications associated with systemic lupus erythematosus (unrelated to her prosthetic valve function). Echocardiographic Results at Last Follow-Up The data in Table 3 were extracted from the last echocardiogram taken after the redo procedure. No patient with autograft preservation has more than 1 AI at follow-up. Although early results are gratifying, the long-term results with autograft preservation after an autograft failure are unknown, and thus these patients continue to be followed annually. Comment The Ross Procedure, as originally conceived, was performed using a subcoronary reimplantation and is still performed as such in several European centers. Early difficulty with this technique as well as the inclusion technique led to the widespread adoption of autograft implantation as a freestanding root. This standard root technique with annular and STJ reinforcement has led to very reproducible results with low morbidity and mortality [2, 3]. For many patients, particularly those with aortic stenosis and normal roots and aortas, long-term results have been very gratifying [1, 9]. There remains a troublesome subset of patients, particularly those with bicuspid aortic valve and aortic insufficiency with aortic disease, who experience autograft dilation. Because both the aorta and pulmonary root form from the conotruncus, dilation of the aorta at the time of a Ross procedure may later be associated with autograft dilation. This usually appears 6 to 8 years postoperatively and often requires reoperation [10 12]. Although annular and STJ reinforcement are effective in stabilizing the freestanding autograft, these patients often exhibit sinus dilation, resulting in a root aneurysm that has minimal to mild AI. Excellent re- Table 2. Postoperative Data After Autograft Redo Surgery Characteristic Autograft Preservation Replacement p Value Total ICU time (h) (median, 33) (median, 24) LOS (days) (median, 5) (median, 5) Postoperative ventilation time (h) (median, 14) 3 3 (median, 4) Cross-clamp time (min) (median, 162) (median, 118) Perfusion time (min) (median, 211) (median, 141) Postoperative blood products used 50% (3/6) 33.3% (3/9) Postoperative Afib % (1/9) Prolonged ventilation usage 16.7% (1/6) Postoperative renal failure 16.7% (1/6) Readmitted within 30 days % (1/9) Two patients were reoperated at another center; 30 day postop data unavailable. Afib atrial fibrillation; ICU intensive care unit; LOS length of stay.

4 ADULT CARDIAC 1480 BRINKMAN ET AL Ann Thorac Surg REDO AUTOGRAFT OPERATIONS AFTER ROSS 2012;93: Fig 1. Cumulative hazards curve comparing accumulation as a function of time of reoperation for patients initially operated on for aortic insufficiency (AI) and aortic stenosis (AS). sults reported by David and coworkers [5] and Yacoub and colleagues [4] with aortic root aneurysm with similar morphology have prompted salvage of the autograft valve with remodeling or reimplantation techniques [13]. Several reports describe disappointing results with leaflet plication or shortening, either alone or as part of a remodeling, with a substantial proportion of repair failures at echocardiographic follow-up [13]. When ascending aortic replacement, isolated sinus replacement with autograft STJ resuspension, autograft valve reimplantation, or root remodeling is used, the shortterm outcomes have been excellent. Although the histopathology of the dilated autograft roots usually demonstrates cystic medial necrosis and loss of elastic fibers, the valve itself is usually very well preserved if autograft dilation has been followed closely and is not severe. The valve retains its trileaflet architecture usually with mild thickening on the ventricular surface [14, 15]. Excellent early results with autograft valve salvage have led most Ross surgeons to adopt a policy of reoperation at 5 cm similar to Marfan and bicuspid aortic valve recommendations. We believe that earlier intervention on the dilated autograft increases the probability for autograft preservation. This report describes patients with increasing AI or increasing autograft dilation with or without AI. Although the annulus had been effectively stabilized in these patients, progressive sinus and ascending aortic dilation necessitated reoperation. In the absence of leaflet prolapse or degeneration, we elected to salvage the autograft with the reimplantation technique to assure annulus, sinus segment, and neo-stj stability. When morphology was mixed leaflet and autograft wall disease, patient preference determined the type of valve or conduit implanted. Most authors reporting Ross reoperations have used ascending aortic replacement with STJ stabilization, the remodeling technique of Yacoub, and leaflet shortening or repair, either alone or in combination with these techniques [12]. We believe that ascending aortic replacement leaves the root and a sinus autograft wall that may subsequently dilate, and the Yacoub technique leaves an annulus that may dilate as a function of time. Leaflet repair alone or in conjunction with other techniques has led to early failures [13]. Our belief is that patients suited to reimplantation have symmetrical sinus dilation with fairly wellpreserved annular and STJ diameters and leaflets without undue stress. Occasionally, an isolated sinus replacement for asymmetric dilation may be all that is necessary at the root level. Success with reimplantation in early patients led to earlier reintervention in our last two autograft reimplantations (patients RG, GS). Although our follow-up is early, results have been gratifying. Reimplantation results in an adynamic root, however, and despite its good results in aortic aneurysmal disease, it may not achieve similar long-term results in the autograft root. One may ask why preserve the autograft during a Ross reoperation for autograft failure? We believe that in a young population younger than 60 years of age that preservation of the autograft is a better option than a bioprosthetic valve Moreover, the cumulative risk with chronic anticoagulation after mechanical valve replacement can be significant [16, 17]. Our present policy is to evaluate all autograft reoperations carefully for reimplantation feasibility. Using transesophageal echocardiography and aortic root computed tomography angiography, the decision for reimplantation can often be made preoperatively and recommended if appropriate. For those patients with eccentric AI jets from leaflet prolapse or patients with very asymmetric roots, we believe composite mechan- Table 3. Data Extracted From the Last Echocardiogram Taken After the Redo Procedure Measurement Autograft Preservation Replacement p Value Follow-up echocardiogram (years after redo) (median, 3.1) (median, 5.8) EF LV diameter (cm) AVA mild aortic stenosis % (1/9) AVA aortic valve area; EF ejection fraction; LV left ventricular.

5 Ann Thorac Surg BRINKMAN ET AL 2012;93: REDO AUTOGRAFT OPERATIONS AFTER ROSS ical or biologic roots offer a better and more reproducible freedom from reintervention. If reimplantation were to result in unacceptable AI, reinstitution of cardiopulmonary bypass and valve replacement within the conduit offers a safe alternative. In view of the good short-term follow-up reported, we believe reimplantation in a selected group of reoperative Ross patients should be strongly considered. The authors wish to thank Ms. Tammy Goodenow for her invaluable assistance and contributions to this work. References 1. Ryan WH, Prince SL, Culica D, Herbert MA. The Ross procedure performed for aortic insufficiency is associated with increased autograft reoperation. Ann Thorac Surg 2011; 91: Chambers JC, Somerville J, Stone S, Ross DN. Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series. Circulation 1997;96: Elkins RC, Thompson DM, Lane MM, Elkins CC, Peyton MD. Ross operation: 16-year experience. J Thorac Cardiovasc Surg 2008;136: e Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115: David TE, Feindel CM, Webb GD, Colman JM, Armstrong S, Maganti M. Long-term results of aortic valve-sparing operations for aortic root aneurysm. J Thorac Cardiovasc Surg 2006;132: David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103: American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; et al. ACC/AHA guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). Circulation 2006;114:e Perry GJ, Helmcke F, Nanda NC, Byard C, Soto B. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol 1987;9: Brown JW, Fehrenbacher JW, Ruzmetov M, Shahriari A, Miller J, Turrentine MW. Ross root dilation in adult patients: is preoperative aortic insufficiency associated with increased late autograft reoperation? Ann Thorac Surg 2011;92: Malvindi PG, van Putte BP, Leone A, Heijmen RH, Schepens MA, Morshuis WJ. Aortic reoperation after freestanding homograft and pulmonary autograft root replacement. Ann Thorac Surg 2011;91: Juthier F, Vincentelli A, Pinçon C, et al. Reoperation after the Ross procedure: incidence, management, and survival. Ann Thorac Surg 2012;93: Luciani GB, Favaro A, Casali G, Santini F, Mazzucco A. Reoperations for aortic aneurysm after the Ross procedure. J Heart Valve Dis 2005;14: de Kerchove L, Boodhwani M, Etienne PY, et al. Preservation of the pulmonary autograft after failure of the Ross procedure. Eur J Cardiothorac Surg 2010;38: Rabkin-Aikawa E, Aikawa M, Farber M, et al. Clinical pulmonary autograft valves: pathologic evidence of adaptive remodeling in the aortic site. J Thorac Cardiovasc Surg 2004;128: Schoof PH, Takkenberg JJ, van Suylen RJ, et al. Degeneration of the pulmonary autograft: an explant study. J Thorac Cardiovasc Surg 2006;132: Birkmeyer NJ, Birkmeyer JD, Tosteson AN, Grunkemeier GL, Marrin CA, O Connor GT. Prosthetic valve type for patients undergoing aortic valve replacement: a decision analysis. Ann Thorac Surg 2000;70: Emery RW, Erickson CA, Arom KV, et al. Replacement of the aortic valve in patients under 50 years of age: long-term follow-up of the St. Jude medical prosthesis. Ann Thorac Surg 2003;75: ADULT CARDIAC DISCUSSION DR JOHN A. KERN (Charlottesville, VA): Bill, I would like to ask you, if I could, I guess your conclusion almost answers my question, part of it. Even though you reinforce the sinotubular junction, the annulus, in, it sounds like, all these patients, the majority of your patients when they failed had insufficiency and dilatation. So I assume you are meaning dilatation of the sinuses. DR BRINKMAN: That is correct, sinus segment dilatation. And we have moved toward a supported Ross technique. We don t have any long-term data on that. DR KERN: That was my next question. Moving forward, how are you changing? And then just one last question. What is your overall experience? How often are you utilizing the Ross in this day and age? Do you think you are using it as much as you did a decade ago? DR BRINKMAN: My experience with the Ross procedure has been about 4 years. Will Ryan, the senior author on the paper, did the lion s share of the work in this series and I would have to defer to his opinion. In my judgment, we reserve the Ross procedure for patients with aortic stenosis, younger patients, less than 60 years of age. Patients with aortic insufficiency and dilated annulus, sinus segment, or aorta, we shy away from the Ross procedure at this point. The other issues, we do not use the Ross procedure in patients with autoimmune problems, such as lupus, as we can see in this series. DR MARK A. GROH (Asheville, NC): That is an excellent talk and you are really doing a great job of following up your patients on this. I had a question for you about practicality of the use of the Ross now in patients with bicuspid valvular diseases. The group that I run into, the biggest problem is about what I should do. Because in this younger group of patients where you see a lot of mixed AS (aortic stenosis)/ai (aortic insufficiency) with them and if the root is dilated at all, is that a group that you would shy away from them completely in and does the bicuspid nature enter into your decision process or not? DR BRINKMAN: Most of the patients in this series in both groups were actually bicuspid patients; in the AS series I believe it was close to 85% bicuspid.

6 ADULT CARDIAC 1482 BRINKMAN ET AL Ann Thorac Surg REDO AUTOGRAFT OPERATIONS AFTER ROSS 2012;93: Things that make us shy away from the Ross procedure are dilatation of the annulus, significant dilatation of the sinus segment or the sinotubular junction, and if it is a predominantly AI situation, we of late have been shying away from the Ross procedure. But if the patient for whatever reason has AI and wants the Ross procedure, we would support a supported Ross technique. DR JOHN V. CONTE (Baltimore, MD): A really nice presentation. I enjoyed it very much. With the encouraging reports of very good outcomes with bioroots with either a stented or stentless pericardial valve, where do you think the Ross procedure is going to fall in the next couple of years? Because certainly a bioroot is much easier technically, there is less chance for technical problems perioperatively, and certainly the reoperation is much easier. So in light of the success of that operation for the aortic root, where do you think the Ross is going to fall going forward? DR BRINKMAN: I think the Ross is going to fall into a younger population who definitely doesn t want a reoperation or coumadin usage. It is difficult to say in light of TAVI (transcatheter aortic valve implantation) and some of the newer things that are coming up and the ideas about valve-in-valve how this will all pan out. I don t have a great answer to that question, to tell you the truth. Notice From the American Board of Thoracic Surgery Regarding Trainees and Candidates for Certification Who Are Called to Military Service Related to the War on Terrorism The Board appreciates the concern of those who have received emergency calls to military service. They may be assured that the Board will exercise the same sympathetic consideration as was given to candidates in recognition of their special contributions to their country during the Vietnam conflict and the Persian Gulf conflict with regard to applications, examinations, and interruption of training. If you have any questions about how this might affect you, please call the Board office at (312) John H. Calhoon, MD Chair The American Board of Thoracic Surgery 2012 by The Society of Thoracic Surgeons Ann Thorac Surg 2012;93: /$36.00 Published by Elsevier Inc