Aortic Root Dilatation S/P Ross Procedure Michael Rechitsky, MD

History 13 y/o male who initially presented for evaluation of progressive dilatation of aortic root after Ross procedure.

MRI Moderately dilated aortic root, measuring up to 42 mm.

Diagnosis Aortic Root Dilatation S/P Ross procedure. Flow quantitation also demonstrated Aortic Valve Regurgitation

DDx Marfan's vs other connective tissue disorders Aortic Regurgitation Associated with Bicuspid Aortic Valves Mycotic Aneurisms

Discussion Options for Aortic Valve Surgery 1. Aortic valve repair (or balloon valvuloplasty for stenosis) 2. Aortic valve replacement - Mechanical valve - Bioprosthetic valve - Homograph valve - Ross procedure Ross Procedure (also called Switch Procedure) younger than 40 to 50, avoid anticoagulation Involves replacing diseased AV with PV. PV is replaced with allograft retrospective review of 301 pt's demonstrated survival and quality of life were significantly better than with other pocedures. Also: 13% vs 45% reoperation at 9 yrs.

Advantages: The pulmonic valve is anatomically very similar to aortic and it will grow as the child or adolescent grows. The blood flows with less pressure through the pulmonary valve than the aortic valve, therefore a homograft valve could last longer in PV, and more tolerated even if fails risk of thromboembolic infection is very low, lower than for any alternative valve prosthesis. hemodynamic performance makes the Ross operation an attractive alternative for athletes. The pulmonary autograft valve has a good chance of being a life-lasting solution for the aortic valve. Drawbacks: technically difficult and long surgery, as it requires two valve replacements, hence also potential to convert 1 diseased valve into 2. Only recommended for young patients who would tolerate a longer bypass time The valve cusps are strong enough to withstand the systemic pressure, but the pulmonary artery wall does dilate when exposed to systemic pressure, occasionally enough to cause the autograft valve to leak. The risk of requiring re-operation for a leaking autograft valve is about 10 percent within 10 years after the operation.

Aortic valve repair Advantages: natural anatomy is preserved, no anticoagulation Drawbacks: technically difficult, not an option for stenotic valves, 20 to 25 percent of patients will require a valve replacement within ten years. Aortic valve replacement 1. Mechanical Valve Replacement Advantages: sturdy, designed to last a lifetime Drawbacks: anitcoaglation 2. Bioprosthetic valve replacement made of tissue, but also have some artificial components Advantages: No Anitcoag Drawbacks: 50 percent chance of lasting 15 years or longer due to accelarated calcification and degeneration 3. Allograft valve replacement Advantages: best and safest option for patients with severe disease, natural anatomy is preserved or restored, and patients do not need to take any blood-thinner medications after surgery. Drawbacks: limited availability, technically difficult. expected to last about 15 to 20 years due to accelarated calcification and degeneration. Like bioprosthetic valves, homografts are not as durable in younger patients.

References Mavroudis, C (2003). Pediatric Cardiac Surgery. Philadelphia, Mosby. Pettersson, G. Aortic Valve Surgery in The Young Adult Patient