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Pulmonary autograft replacement in children. The ideal solution?
R C Elkins1, K Santangelo, J D Randolph
1University of Oklahoma Health Sciences Center, Oklahoma City 73190.
Insights
The pulmonary autograft is an ideal aortic valve replacement in children, showing excellent function and growth. This procedure offers low risk, with freedom from reoperation at 93% and resolution of heart abnormalities.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Thoracic Surgery
Background:
- Aortic valve disease in children often necessitates valve replacement.
- The pulmonary autograft (Ross procedure) is a viable option for aortic valve replacement in pediatric patients.
- Long-term outcomes and growth characteristics of pulmonary autografts in children require continued evaluation.
Purpose of the Study:
- To review the outcomes of pediatric patients undergoing aortic valve replacement with a pulmonary autograft.
- To assess the functional status, reoperation rates, and echocardiographic findings in children receiving pulmonary autografts.
- To evaluate the impact of pulmonary autograft replacement on left ventricular (LV) mass index and hemodynamics.
Main Methods:
- Retrospective review of 51 children (aged 1.8–21 years) who underwent aortic valve replacement using a pulmonary autograft.
- Categorization of procedures into intra-aortic implants (29) and root replacements (22).
- Analysis of operative mortality, late mortality, reoperation rates, progression of aortic insufficiency (AI), echocardiographic findings, and LV mass index.
Main Results:
- One operative death and no late deaths; 2 patients required reoperation (93% +/- 5.5 freedom from reoperation at 5.6 years).
- Freedom from progression of AI was 81% +/- 9 (intra-aortic) and 86% +/- 10 (root replacement) at 5.6 years.
- Echocardiography showed autograft enlargement consistent with somatic growth, not AI progression. Preoperative LV hypertrophy resolved in most patients within 1 year post-surgery.
Conclusions:
- The pulmonary autograft demonstrates excellent function and low operative risk for pediatric aortic valve replacement.
- Autograft enlargement is physiological, correlating with somatic growth and not adverse AI progression.
- The pulmonary autograft is suggested as the ideal replacement for malfunctioning aortic valves in children, promoting normalization of LV hemodynamics.
Abstract:
Fifty-one children, aged 1.8 to 21 years (mean, 11.4) with aortic valve replacement using a pulmonary autograft are reviewed. Twenty-nine were intra-aortic implants and 22 were root replacements. There was one operative death, no late deaths, and two have required reoperation. Actuarial freedom from reoperation was 93% +/- 5.5 at 5.6 years. Freedom from progression of aortic insufficiency (AI) was 81% +/- 9 at 5.6 years in the intra-aortic implants and 86% +/- 10 in the root replacement. Enlargement of the pulmonary autograft was seen echocardiographically in both groups. This enlargement was consistent with somatic growth and not associated with progression of AI. Ten of 19 patients with aortic stenosis had an LV mass index suggestive of LV hypertrophy before operation. At 1 year, 18 of 25 had a normal LV mass index. Thirteen of 16 patients with AI had preoperative abnormal LV mass index. All but four returned to normal by 1 year. Low operative risk, excellent function, resolution of abnormal LV hemodynamics, and enlargement consistent with somatic growth suggest that the pulmonary autograft is the ideal replacement for the malfunctioning aortic valve.