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J Thorac Cardiovasc Surg 1999;117:614-616
© 1999 Mosby, Inc.

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SIX-YEAR FOLLOW-UP OF A PULMONARY AUTOGRAFT IN THE MITRAL POSITION: THE ROSS II PROCEDURE

From the Department of Cardiovascular Diseases (MBC-16), King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.

Received for publication Oct 20, 1998. Accepted for publication Oct 31, 1998. Address for reprints: Zohair Al Halees, MD, FACS, Department of Cardiovascular Diseases, King Faisal Specialist Hospital, MBC 16, PO Box 3354, Riyadh 11211, Saudi Arabia.

The autologous pulmonary valve was translocated into the mitral valve position in a rheumatic and symptomatic 12-year-old girl with severe mitral valve regurgitation. The top hat technique was used. The native mitral valve was totally preserved. The patient continues to do well with a normally functioning translocated pulmonary autograft after 6 years of follow-up. We propose to call this procedure the "Ross II procedure."

Clinical summary

A 12-year-old girl weighing 30 kg with a body surface area of 1.16 m² was referred to us with the diagnosis of severe rheumatic mitral valve regurgitation. She was in New York Heart Association class III-IV despite receiving diuretics and angiotensin-converting enzyme inhibitors. Both weight and height were below the fifth percentile for age. She had signs and symptoms of severe mitral valve regurgitation. A 2-dimensional echocardiogram demonstrated a rheumatic mitral valve with large lack of coaptation of valve leaflets, prolapse of the anterior leaflet, and thickening of the tips of both leaflets. There was severe mitral regurgitation with an eccentric jet, which was directed posteriorly and filled a massively dilated left atrium. The other valves were normal. The left ventricle was dilated but had normal systolic function.

The patient was operated on with the use of routine cardiopulmonary bypass and retrograde continuous warm blood cardioplegia. The mitral valve appearance was consistent with healed rheumatic valvulitis with a severely thickened, retracted posterior leaflet. The anterior leaflet was thin and pliable with mild prolapse. An attempt at repairing the valve was unsuccessful. Because of the patient's age and unsuitability for permanent anticoagulation, we decided to use the patient's own pulmonary valve. The pulmonary valve was harvested and implanted inverted in the mitral position inside a 26-mm Dacron tube, a technique described by Yacoub and Kittle ¹ as "the top hat." The native valve was left intact in its position. Right ventricular–pulmonary artery continuity was re-established with a size 24 cryopreserved pulmonary homograft.

An intraoperative transesophageal echocardiogram demonstrated a well-functioning pulmonary autograft in the mitral position with only trivial regurgitation and no restriction to flow. The pulmonary homograft in the pulmonary position was also functioning well with no pulmonary stenosis or regurgitation. The native mitral valve was seen in the left ventricle with preserved mitral annular contraction. Both ventricles showed normal systolic function. The patient made an uneventful recovery.

The patient has had annual follow-up examinations, including complete transthoracic 2-dimensional echocardiographic assessment. She is free of symptoms in New York Heart Association class I and continues to thrive. Her maintenance drug program includes oral penicillin V prophylaxis 250 mg twice daily and aspirin 100 mg daily. The latest echocardiogram 6 years later showed the pulmonary autograft in the mitral position functioning well with mild thickening of the cusps (Fig. 1). There was mild mitral regurgitation and a mean diastolic gradient of 8 mm Hg. The effective orifice area was calculated as 1.7 cm². Left atrial size had decreased significantly and both ventricles were normal in size and function (Fig. 2). The pulmonary homograft in the pulmonary position functioned normally.

View larger version (80K): [in this window] [in a new window]   Fig. 1. Apical 4-chamber echocardiographic view of the pulmonary autograft in the mitral position 6 years after the operation. A, Systolic frame. B, Diastolic frame. LA, Left atrium; LV, left ventricle; MV, mitral valve; PV, pulmonary autograft in mitral position; RA, right atrium; RV, right ventricle; HR, heart rate.

View larger version (112K): [in this window] [in a new window]   Fig. 2. A, Doppler flow imaging showing very mild regurgitation of the autograft and B, continuous wave Doppler, Mean diastolic gradient = 8 mm Hg. Vmax, Maximum velocity; Vmean, mean velocity; Pmax, maximum pressure; Pmean, mean pressure; VTI, velocity time interval. For other abbreviations see Fig 1.

Valvular repairs are preferable but not feasible all the time. Valvular replacement with a mechanical prosthesis or bioprosthesis is not without drawbacks. Homograft replacement has inherent limitations of acellularity, degenerative changes, calcification, and limited life span. The search for an ideal valvular replacement that would resist degeneration and infection, has a good effective orifice area, low pressure gradients, and freedom from thromboembolic consequences or leak is still far from reach. ² This would be particularly important in young persons to avoid a lifetime of anticoagulation or the possibility of increasingly hazardous reoperations.

Aortic valve replacement with the pulmonary autograft (the Ross operation) is a good option, and in several cohorts of patients impressive results have been demonstrated. ^2,3 Although the use of the pulmonary autograft in the mitral position was mentioned in Ross's original article, ⁴ only one report of implanting the native pulmonary valve in the mitral position has appeared in the recent medical literature. ⁵ Ross had an initial series, but unfortunately the follow-up is fragmentary. Nevertheless, he demonstrated that the technique is feasible and that the pulmonary valve can function well inverted in the mitral position for up to 14 years. ⁵

The pulmonary autograft proved tolerant to the high systemic pressure. The cusps slowly thickened and adapted to the new situation. It has also been reported that explanted valves showed normal cusp cellularity with no evidence of tissue degeneration. ² The autograft has the advantage of being living autogenous tissue. Hence the potential for growth exists when the pulmonary autograft is used in the aortic position, and that is the reason the Ross operation is considered ideal for aortic valve replacements in infants and children. However, the potential for growth is lost when the pulmonary autograft is used in the mitral position because it has to be housed within the Dacron tube. On the other hand, inasmuch as the autograft is lying in the left atrium as a top hat, a partial or total preservation of the mitral valve apparatus is feasible, as was done in our patient. The autograft is a living autogenous tissue, fully flexible, and it cannot obstruct the left ventricular outflow tract because of its position inside the left atrium (Figs. 1 and 2).

The improved clinical condition of our patient, freedom from anticoagulation, absence of thromboembolism, and the maintained excellent performance of the pulmonary autograft in the mitral position 6 years later cautiously support this procedure as a viable alternative in specific clinical situations requiring replacement of the mitral valve. However, a larger number of patients is needed with longer follow-up periods before one can confidently advocate this procedure. Inasmuch as it is another innovation from a pioneer surgeon, we suggest calling this procedure the Ross II procedure.

References

1. Yacoub MH, Kittle CF. A new technique for replacement of the mitral valve by a semilunar valve homograft. J Thorac Cardiovasc Surg 1969;58:859-69. [Medline]
   
2. Ross D, Jackson M, Davies J. The pulmonary autograft—a permanent aortic valve. Eur J Cardiothorac Surg 1992;6:113-7. [Abstract]
   
3. Kumar N, Prabhakar G, Gometza B, Al Halees Z, Duran CMG. The Ross procedure in a young rheumatic population: early clinical and echocardiographic profile. J Heart Valve Dis 1993;2:376-9. [Medline]
   
4. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 1967;2(523):956-8. [Medline]
   
5. Ross DN, Kabbani S. Mitral valve replacement with a pulmonary autograft: the mitral top hat. J Heart Valve Dis 1997;6:542-5. [Medline]
   

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