Modification of the Ross aortic valve replacement to prevent late autograft dilatation☆

This is an interesting article [1]. We enthusiastically support the use of Dacron graft in Ross operation to prevent aortic dilation in long term. The diameter of sinus of Valsalva increases by 16% during systole in native aorta [2] (although thicker than native pulmonary artery). As the Dacron graft could not change its diameter during systole, we think that this may cause an increase in incidence of aneurysm/dissection formation. To overcome this problem, would it be more convenient to insert Dacron graft between coronary buttons? † The corresponding author of the original article [1] was invited to reply but did not respond. REFERENCES[1] Brown JW, Ruzmetov M, Shahriari AP, Rodefeld MD, Mahomed Y, Turrentine MW. Modification of the Ross aortic valve replacement to prevent late autograft dilatation. Eur J Cardiothorac Surg 2010;37: 1002-7. [2] Thubrikar MJ, Nolan SP, Aouad J, Deck JD. Stress sharing between the sinus and leaflets of canine aortic valve. Ann Szabo et al. [1] demonstrated that administration of tetrahydrobiopterin (BH4) during early reperfusion improves cardiopulmonary recovery after cardioplegic arrest and extracorporeal circulation in dogs. Application of BH4 restored myocardial, endothelial, and pulmonary function and increases plasma cyclic guanosine monophosphatase (cGMP) levels. Szabo et al. concluded that the beneficial effect of BH4 on reperfusion injury after cardiopulmonary bypass can be explained by recoupling of endothelial nitric oxide synthase (eNOS), as supported by increased cGMP levels measured by radioimmunoassay. However, there are many factors that can cause induction of cGMP other than NO, such as carbon monoxide and natriuretic peptides [2], which are also released in ischemia/reperfusion damage [3]. In addition, plasma arterial cGMP is correlated with atrial natriuretic peptide levels, and its production is secondary to an enhancement of the local tissue cGMP of the vascular bed [4]. It is required to measure natriuretic peptide to exclude this as another factor of cGMP production. Moreover, there are several more direct ways to evaluate eNOS coupling, such as eNOS monomer/dimer analysis, eNOS activity, eNOS-dependent superoxide generation, and quantification of BH4 and BH2 levels [5].In addition, it is not clear whether the dose of BH4 that is used in the study of Szabo et al. increases myocardial and endothelial levels of BH4. Subsequently, it is unclear whether the improved leftventricular function is due to improved myocyte function or is † The corresponding author of the original article [1] was invited to reply but did not respond.

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This is an interesting article [1]. We enthusiastically support the use of Dacron graft in Ross operation to prevent aortic dilation in long term.

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mentioning

confidence: 82%

“…Szabo et al [1] demonstrated that administration of tetrahydrobiopterin (BH4) during early reperfusion improves cardiopulmonary recovery after cardioplegic arrest and extracorporeal circulation in dogs. Application of BH4 restored myocardial, endothelial, and pulmonary function and increases plasma cyclic guanosine monophosphatase (cGMP) levels.…”

mentioning

confidence: 99%

Is re-modification of Ross operation necessary?

Yurekli

Kestelli

Gokalp

et al. 2011

European Journal of Cardio-Thoracic Surgery

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“…Brown et al 12) described a preventive method of dilation for both sites in which the ascending aorta is replaced with a tubular Dacron graft, and also added external fixation of the aortic annulus with a Dacron strip. They also emphasized that postoperative systemic hypertension must be aggressively treated.…”

Section: Prevention Of Graft Failurementioning

confidence: 99%

Ross Procedure: Prognosis of Pulmonary Autografts

Kobayashi

2012

ATCS

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“…Pulmonary autograft dilatation is common after the Ross procedure in adults, and this might be a cause of reoperation Aljassim et al, 2011). Patients with BAV and dilated ascending aortas, or patients with dilated aortic root and primarily AR, have been considered the highest-risk groups for dilatation and neo-aortic valvular regurgitation (Tantengco et al, 1999;Simon-Kupilik et al, 2002;Kouchoukos et al, 2004;Brown et al, 2010). Perhaps the modified Ross procedure, as described by Ungerleider et al, in which the autograft is completely encased in a Dacron graft before implantation, may provide better results in patients with preoperative ascending aortic and sinus dilation.…”

Section: Aortic Valve Replacementmentioning

confidence: 99%

“…The Ross operation is an acceptable alternative to conventional aortic valve replacement and has been shown to provide excellent hemodynamic results. The advantages of this therapeutic option are the use of a viable autologous valve and a low incidence of infection and thrombogenicity, avoidance of anticoagulant therapy, as well as its potential to grow in children (Hanke et al, 2007;Brown et al, 2010;Sievers et al, 2010;Ryan et al, 2011). Nevertheless, there is growing concern about autograft failure and surgical revisions because of the frequently concomitant aortic root and tubular ascending aorta pathology observed in many patients with BAV , and the intrisic abnormalities in the wall of the pulmonary artery based on the common embryological origin of the aortic and pulmonary root, which may contribute to progressive neoaortic root dilatation and AR, or both, when the pulmonary root is placed in the systemic position Siu & Silversides, 2010;Hanke et al, 2010).…”

Section: Aortic Valve Replacementmentioning

confidence: 99%