Insertion of the pulmonary autograft as an inclusion cylinder--modifications to existing techniques

Ten pulmonary autograft procedures have been performed (mean age 27, range 19-40 years) all using root replacement techniques. In six operations the inclusion cylinder method was performed, as first preference. Because of root asymmetry associated with the congenitally deformed aortic valves, modifications to the standard procedure were necessary in four out of the six patients. In one, the aortic annular dimension was reduced by a Dacron collar inserted around the proximal autograft suture line. In another the sinotubular dimension was trimmed by wedge excision of part of the non-coronary sinus and ascending aortic tailoring. In the remaining two patients, pericardial patch enlargement of the lower ascending aorta was employed to increase the sino-tubular diameter. In the remaining four patients, full free-standing root replacement was performed as second best option because of inexperience (early in the series), or coronary artery anomalies, and more severe degrees of root symmetry (later in the series). All 10 patients are alive and have been recently reviewed with Doppler echocardiography (mean follow up 14 months, range 4-29 months). Mean aortic gradient was 5 mmHg, aortic regurgitation minimal (trivial seven, mild three), good pulmonary homograft function and normalization of left ventricular function were documented. In summary, we aim to perform the inclusion cylinder technique in most cases, and it is presumed that this may result in better long term aortic valve competence.