Ann Thorac Surg 2005;80:494
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Christophe Acar, MD
Cardiovascular Surgery, Hôpital de la Salpétrière, 50–52 Bd Vincent Auriol, Paris, 75013 France
(Email: c.acar{at}psl.ap-hop-paris.fr).
The experience of Kumar and colleagues offers an extensive and detailed 10-year appraisal of the Ross procedure. However it is characterized by a relatively small number of patients in the growing age and a complete absence of any major pediatric cardiac operation (Ross Konno), which probably accounts for an in-hospital mortality lower than what has been reported by others [1]. In addition, 3 out of 4 cases were primarily operated on for bicuspid aortic valves. Thus it can be speculated that the frequent occurrence of autograft dilatation in this series (only 43% freedom from dilatation at 10 years) was related to dystrophy of the arterial wall known to be frequently combined with the bicuspid aortic valve. Aortic valve repair would have been another therapeutic option; unfortunately the lack of resistance of the cusp tissue can be responsible for suture dehiscence [2]. When compared with other biological devices, this series of Ross procedures appears to offer freedom from reoperation comparable with porcine bioprostheses [3] or aortic homografts [4] in a comparable population aged 20 to 40 years (approximately 80% at 10 years). On the other side, a mechanical valve would have offered a superior durability with an additional risk of bleeding, which along with a bileaflet valve in the aortic position and a low target international normalized ratio of 1.5 to 2.5, can be considered minimal in knowing the patient’s age [5]. When dilated, replacement of the supracoronary portion of the ascending aorta with a Dacron tube could have been achieved with virtually no additional risk.
The author’s policy is to propose a Ross procedure to every single patient whose life expectancy exceeds 20 years. Halfway to the end of the study, his data does not entirely support this strategy. We believe that the last statement of the present article, the Ross operation is the preferred surgical option ... due to the unsurpassed survival and quality of lifeshould be more carefully restricted to the group of patients less than 20 years of age and in whom a biological subsitute is absolutely necessary.
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References
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- Cosgrove DM, Rosenkranz ER, Hendren WG, Bartlett JC, Stewart WJ. Valvuloplasty for aortic insuffisance J Thorac Cardiovasc Surg 1991;102:571-577.[Abstract]
- Jamieson WRE, Ling H, Burr LH, et al. Carpentier Edwards supraannular porcine bioprosthesis evaluation over 15 years Ann Thorac Surg 1998;66:S49-S52.
- O’Brien MF, Harrocks S, Stafford EG, et al. The homograft aortic valvea 29 year, 99.3% follow-up of 1022 valve replacements. J Heart Valve Dis 2001;10:334-335.[Medline]
- Akins CW. Results with mechanical cardiac valvular prostheses Ann Thorac Surg 1995;60:1836-1844.[Abstract/Free Full Text]
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