[HSF] Ao Wraping

Sat Mar 31 22:23:59 EDT 2007

Ed

Just a small correction - quoting your freedom from reoperation as 98% is somewhat inaccurate. You should present an actuarial figure and with two reoperations, the reoperation rate could be higher than you think. For example, assuming these two patients were one of four patients you did in your first year (I.e. one of only four to have survived 10 years) then your actuarial reoperation rate at 10 years would be 50% and not 2%!

There is no doubt that the Ross can be done with as low a mortality as a stented AVR by those who do the procedure often - several series have demonstrated this, so on safety basis there is no reason to discontinue the use of the procedure. The question really is its efficacy, and that is unanswered and it is uncertain as to whether the durability in adults is better than a pericardial valve. Data from Yacoub's randoized trial shows the Ross better than allograft, but unfortunately that may have been the wrong question and maybe the Ross should have been randomized to the pericardial valve.

Actually Takkenberg has a paper in press (electronic version available through pubmed) and the results, although painted as excellent are not really that fantastic. Most series show that the reoperation rate at 15 years is about 25% when one adds autograft and pulmonary reoperations. Percutaneous valves could however change that as will modifications to the autograft procedure as you describe so it might well be that current patients will have a much lower reoperation rate (though will have a percutaneous reintervention rate).

Ani
  ----- Original Message ----- 
  From: DukeB60 at aol.com<mailto:DukeB60 at aol.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Saturday, March 31, 2007 4:21 PM
  Subject: Re: [HSF] Ao Wraping

  The controversy unquestionably exists with  the Ross and the concerns are 
  well founded.  Usually the decision for my  patients comes down to a minimally 
  invasive partial upper sternotomy Magna vs. a  Ross.  Very few patients choose 
  the mechanical valve and life long  coumadin with the one to one and a half 
  percent per year risk of bleeding  or thrombotic complications which are 
  cumulative over the life of the patient or  the valve.  In my personal series the 
  operative mortality is under one  percent with the only death being in a 23 yo 
  male redo who had an infected  mechanical prosthesis with destruction of the 
  annulus who died from MOF due to  sepsis.  He could have had an allograft root 
  replacement or the Ross but I  don't think it was the decision to do the Ross in 
  his particular case that  resulted in the unfortunate outcome.  So far two 
  have been reoperated for  autograft dilation and in those two one had his 
  ascending aorta only replaced  with preservation of the neo-aortic valve and the 
  other had a root including  valve replacement after a failed attempt to repair the 
  autograft valve.   Both are doing fine.  Although my follow up is admittedly 
  not complete and  the number of years out varies from ten years to days the 
  operative  mortality is less than one percent and the freedom from reop is 98  
  percent.  A few of the Ross's have involved redo's to remove  mechanical valves 
  as the patients had failed valves either due to infection or  pannnus and 
  wanted to get off of coumadin. One case involved the removal of a  Starr-Edward's 
  ball-cage valve with the dacron covering which had  frayed that was causing 
  TIAs and he elected to have a Ross for his  replacement  The Ross reops I have 
  done were quite easy and both were prior  to buttressing the autograft with 
  the Hemashield.  There have been no  instances of allograft stenosis or injury 
  to the first septal perforator,  although one must be very aware of the latter 
  to avoid it.  Our aortic root  conference next October with Sir M. Yacoub 
  focuses a fair amount of attention to  the Ross and Dr. Takkenburg will look at 
  the long term data for the Ross.   I'm not sure it is a dead option at all but 
  it is without question a much more  demanding and controversial procedure than 
  a simple prosthetic  replacement.  

  Edward P.  Raines, M.D., J.D.
  BryanLGH Cardiothoracic Surgery
  BryanLGH Medical Center  East
  1600 South 48th Str.
  Lincoln, Nebraska 68506
  Office:  402-481-8430
  Cell: 402-730-9242
  Fax:  402-481-8429

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