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Address reprint requests to: Igor E. Konstantinov, MD, PhD, FRACS, Department of Cardiac Surgery, Royal Children's Hospital, Flemington Rd, Parkville, VIC 3052, Australia.
Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia.Department of Paediatrics, University of Melbourne, Melbourne, Australia.Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
Address reprint requests to: Igor E. Konstantinov, MD, PhD, FRACS, Department of Cardiac Surgery, Royal Children's Hospital, Flemington Rd, Parkville, VIC 3052, Australia.
Affiliations
Department of Paediatrics, University of Melbourne, Melbourne, Australia.Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.The Royal Melbourne Hospital, Melbourne, Australia.
Autograft stabilization has proven beneficial in adults but the same technique could not always be adopted in growing children undergoing the Ross procedure. The major concern regarding the longevity of autograft after the Ross operation in a growing child is the lack of means to stabilize the aortic root. Herein we described a modified root inclusion technique that achieves aortic root stabilization using autologous tissue.
The modified root inclusion technique is simple and reproducible, permitting complete wrapping of the native aortic root around the autograft in children. This technique ensures stabilization of the autograft.
Introduction
Although aortic valve repair is preferred in growing children,
In children, however, stabilization is not straightforward, due to the need to allow somatic growth. We have recently demonstrated that the Ross procedure performed in the re-operative setting in children has a lower risk of autograft reoperation, presumably related to intrinsic stabilization due to increased tissue fibrosis following the previous surgery.
Thus, conceptually, it appears that thickened native tissue around the autograft prevents autograft failure in a growing child. Therefore, we try to emulate the same concept in our modified root inclusion technique detailed herein that, in our opinion, is most applicable to a growing child. (Figs. 1-7)
Figure 1Exposure of the aortic annulus. The aorta is partially opened leaving the posterior aortic wall above the left coronary artery intact. The aortic valve is removed. Commissural stay stitches and mobilization of the right coronary artery facilitate exposure of the aortic annulus. (Color version of figure is available online at www.optechtcs.com.)
Figure 2Reinforcement of the posterior wall of the right ventricular outflow tract. As cardioplegia is given the hemostasis at the site of autograft removal is secured and the posterior wall of the right ventricular outflow tract is reinforced with pledget sutures as it would be difficult to access this area after the Ross procedure. Great caution must be exercised to take superficial bites and avoid distortion of the left main coronary artery. (Color version of figure is available online at www.optechtcs.com.)
Figure 3Implantation of the autograft. Implantation of the autograft begins at the nadir of the left coronary cusp. We use 3 separate 4-0 Prolene (Johnson & Johnson, New Brunswick, NJ) sutures starting at the nadir of each cusp to ensure that the autograft is symmetrically implanted, this technique helps to ensure there is no distortion of the autograft. Care must be taken to ensure equal spacing of sutures to minimize the risk of aortic regurgitation. Suture placement should be close to the hinge point of the autograft leaflets, and the autograft should be seated within the native annulus to reduce the risk of annular dilatation. Subsequently, the second layer of 5-0 Prolene circumferential suture is placed to ensure hemostasis. (Color version of figure is available online at www.optechtcs.com.)
Figure 4Implantation of the left coronary artery. The left coronary artery is left in situ and implanted into the autograft. Leaving the left coronary artery in its native position eliminated the risk of coronary artery distortion. (Color version of figure is available online at www.optechtcs.com.)
Figure 5Implantation of the right coronary artery. The incision is made in the middle of the corresponding sinus of the autograft. The right coronary artery is implanted so that the edges of the autograft are connected to each other above the coronary button to avoid inadvertent enlargement of the sino-tubular junction. (Color version of figure is available online at www.optechtcs.com.)
Figure 6Reconstruction and stabilization of the aortic root. The posterior wall of the autograft is sutured to the undivided posterior wall of the native aorta (A). The anterior wall of the autograft is sutured incorporating all 3 layers (i.e., autograft and the edges of the native aorta) into the suture line (B). The suture line at the sino-tubular junction is covered and reinforced with a strip of the autologous pericardium (C). (Color version of figure is available online at www.optechtcs.com.)
Figure 7Wrapping of the ascening aorta with autologous pericardium. . The autologous pericardial strip is typically taken from the diaphragmatic surface, where it is strongest. The pericardium is wrapped around the sino-tubular junction and sutured to the ascending aorta. The pericardial strip is tailored so that sino-tubular junction and the echocardiographic annulus of the aortic valve are approximate the same diameter. (Color version of figure is available online at www.optechtcs.com.)
Several techniques of autograft support have been described, aimed at stabilization of the aortic root that may improve autograft freedom from regurgitation, dilatation, and reoperation.
We have previously demonstrated that the use of PDS bands to support the STJ in children undergoing the Ross procedure was associated with a reduced incidence of moderate or greater autograft regurgitation (0% Vs 20%, P = 0.04, at a median follow-up 7 years).
Meanwhile, in adults, it has been shown that autograft stabilization significantly improved freedom from autograft reoperation at 10 years (93% Vs 88%, P = .001).
However, in a growing child root stabilization involving prosthetic material is problematic. Thus, we describe a simple modified root inclusion technique that stabilizes the aortic root using exclusively autologous tissue. We expect that by avoiding synthetic tissue we can achieve stabilization while preserving a normal growth potential.
In 1967 Donald Ross first described the use of a transplanted pulmonary autograft to replace an aortic valve in twelve patients stating that “As a living autograft, the transplanted pulmonary valve has the prospect of long-term or permanent survival, whilst retaining the advantages of an aortic homograft” the latter being the prevailing implant for aortic valve replacement at that time.1 Fast forward 55 years later, Mr. Ross’ prediction of long-term or permanent survival of the autograft remains controversial, particularly as it is applied to young and rapidly growing children and young infants who arguably would benefit the most from his procedure.
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