Similarities and Differences of the Aortic Root After Arterial Switch and Ross Operation in Children

doi:10.1016/j.amjcard.2012.08.059

The American Journal of Cardiology

Volume 111, Issue 1, 1 January 2013, Pages 125-130

https://doi.org/10.1016/j.amjcard.2012.08.059 Get rights and content

Pulmonary root dilation and valve regurgitation if translocated into the aortic position is frequently seen in children with transposition of the great arteries (TGA) after an arterial switch operation, as well as in patients after the Ross procedure. Many mechanisms are thought to be responsible for the progressive dilation. Despite the differences between the 2 groups, the similarity of having the pulmonary valve and its adjacent tissue working in the systemic circulation might have a comparable effect on the neoaortic root dimensions and elasticity. We prospectively recruited 52 patients with TGA, 23 Ross patients, and 48 healthy subjects for echocardiographic assessment of their aortic valve, root, sinutubular junction, and ascending aortic dimensions and elasticity. The data were compared, stratified by patient age at investigation and the duration of follow-up postoperatively. In relation to the healthy subjects, the neoaortic root dimensions were significantly larger and the tissue stiffer and less distensible in those with TGA and those who had undergone the Ross procedure. Although the pulmonary valve of the Ross patients had been under systemic pressure load for a significantly shorter period (4.4 ± 3.6 vs 10.1 ± 5.5 years), the dimensions and elasticity values had deteriorated more. These differences could neither be clearly attributed to the age differences at surgery or to an auxiliary congenital ventricular septal defect in those with TGA or the aortic valve phenotype before the Ross operation. In conclusion, the worse outcome of the neoaortic root dimensions and elasticity in the Ross patients should at least be partly related to the different predefined pulmonary artery structures and the different development of the normal and transposed pulmonary arteries.

Section snippets

Methods

The patients were selected through a review of the institutional pediatric cardiology and echocardiography database of the Pediatric Heart Center (Vienna, Austria). The inclusion criteria were age ≤18 years in both patient subgroups. Only isolated complete TGA corrected by single-stage ASO, including the Lecompte maneuver, with only additional ventricular septal defects and/or coarctations of the aorta, were accepted. Of the Ross patients, only those who had undergone the full root replacement

Results

The demographic data are listed in Table 1. As expected from the male predominance in TGA and congenital aortic valve diseases, statistically meaningful differences for this value were found. Significantly larger diameters and greater z scores were found in AV, AoR, STJ, and ascending aorta in patients after ASO than in the control subjects. Similarly, the elastic properties of the aortic root showed significantly stiffer and less distensible values in patients with TGA. Regarding the diameters

Discussion

We were able to show an obvious increase in the neoaortic dimensions and stiffness, together with a remarkable decrease in distensibility of the neoaortic root, in both patient populations compared to healthy children and adolescents. This disproportional increase in dimensions started in the first year after surgery and was neither accompanied, nor provoked, by aortic regurgitation. Despite the shorter time of pressure load to the pulmonary valve in the systemic circulation in the Ross

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Cited by (9)

Time course and predictors for neoaortic root dilatation and neoaortic valve regurgitation during adult life after arterial switch operation
2021, Revista Espanola de Cardiologia
Hay pocos datos sobre la evolución en adultos de la dilatación de la raíz neoaórtica (RAO) y la insuficiencia valvular neoaórtica (IA) tras la cirugía de switch arterial (SA) en la transposición de grandes arterias.
Análisis retrospectivo de 152 pacientes con transposición de grandes arterias, mayores de 15 años, intervenidos mediante SA y seguidos durante 4,9 ± 3,3 años en 2 centros de referencia. Se analizaron los cambios de diámetro de la RAO ajustados a superficie corporal y la progresión a grado moderado/grave de la IA con ecocardiografías seriadas. Se realizó un modelo de regresión de Cox para identificar factores predictores de progresión de la IA.
Inicialmente, 4 pacientes (2,6%) presentaban IA grave (3 habían precisado cirugía valvular) y 9 (5,9%) moderada. La RAO basal media era 20,05 ± 2,4 mm/m², y al final del seguimiento, 20,73 ± 2,8 mm/m² (p < 0,001), con un crecimiento medio de 0,14 (IC95%, 0,07-0,2) mm/m²/año. La IA progresó en 20 (13,5%) y 6 (4%) fueron intervenidos. La progresión de IA se asoció con válvula bicúspide, IA inicial, dilatación de la RAO inicial y crecimiento de la RAO. La válvula bicúspide (HR = 3,3; IC95%, 1,1-15,2; p = 0,037), la IA inicial (HR = 5,9; IC95%, 1,6-59,2; p = 0,006) y el crecimiento de la RAO (HR = 4,1; IC95%, 2-13,5; p = 0,023) resultaron predictores independientes.
La dilatación de la RAO y la IA progresan en el adulto joven intervenido mediante SA. La válvula bicúspide, la IA basal y el crecimiento de la RAO son predictores de progresión de IA.
There are limited data on the long-term development of neoaortic root dilatation (NRD) and neoaortic valve regurgitation (AR) after arterial switch operation (ASO) for transposition of the great arteries during adult life.
We performed a retrospective longitudinal analysis of 152 patients older than 15 years who underwent ASO for transposition of the great arteries and who were followed-up for 4.9 ± 3.3 years in 2 referral centers. Sequential changes in body surface-adjusted aortic root dimensions and progression to moderate/severe AR were determined in patients with 2 or more echocardiographic examinations. Risk factors for dilatation were tested by Cox regression to identify predictors of AR progression.
At baseline, moderate AR was present in 9 patients (5.9%) and severe AR in 4 (2.6%), of whom 3 had required aortic valve surgery. Initially, the median neoaortic root dimension was 20.05 ± 2.4 mm/m², which increased significantly to 20.73 ± 2.8 mm/m² (P < .001) at the end of follow-up. The mean change over time was 0.14 mm/m²/y (95%CI, 0.07-0.2). Progressive AR was observed in 20 patients (13.5%) and 6 patients (4%) required aortic valve surgery. Progressive AR was associated with bicuspid valve, AR at baseline, NRD at baseline, and neoaortic root enlargement. Independent predictors were bicuspid valve (HR, 3.3; 95%CI, 1.1-15.2; P = .037), AR at baseline (HR, 5.9; 95%CI, 1.6-59.2; P = .006) and increase in NRD (HR, 4.1 95%CI, 2-13.5; P = .023).
In adult life, NRD and AR progress over time after ASO. Predictors of progressive AR are bicuspid valve, AR at baseline, and increase in NRD.
Long-term survival and reintervention after the Ross procedure across the pediatric age spectrum
2015, Annals of Thoracic Surgery
There are limited data regarding long-term outcomes after the Ross procedure in children. We evaluated mortality and reintervention in a large pediatric cohort.
A retrospective analysis of all patients aged younger than 18 years who underwent the Ross procedure at our institution (1991 to 2013) was conducted. Kaplan-Meier curves and Cox proportion hazard models were used to evaluate long-term outcomes and associated risk factors.
Included were 240 consecutive patients undergoing a Ross/Ross-Konno procedure: 18% infants, 48% children, and 33% adolescents. Infants were more likely to have complex left heart disease (p = 0.005). Overall survival to hospital discharge was 96%; infants had the highest mortality (18%). Long-term survival status was known for 99.6% (median follow-up, 10.7 years). Overall 15-year survival was 87% (lowest in infants, 72%; p = 0.003). Reintervention status was known in 87%. Overall 15-year freedom from any left ventricular outflow tract reintervention was 59%; 85% still had their autograft valve at the latest follow-up. Left ventricular outflow tract reintervention was uncommon in infants (n = 2). Overall 15-year freedom from right ventricular outflow tract reintervention was 53%, and was lower in infants (19%) than in children (51%) and adolescents (76%; p < 0.0001).
Outcomes after the Ross procedure in children vary by age. Infants more commonly have complex left heart disease and experience higher mortality but have excellent long-term autograft durability. Children and adolescents have higher rates of left ventricular outflow tract reintervention, whereas infants are at highest risk of right ventricular outflow tract reintervention.
A modification of the pulmonary autograft procedure to prevent late autograft dilatation
2014, Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac Surgery Annual
Citation Excerpt :
Finally, there has been increasing concern about the incidence of aortic dilation that occurs late, and eventually in most patients who receive the pulmonary autograft procedure.3,9,18–22 The consequence of neo aorta dilation has been described following arterial switch (which provides an analogous situation to the pulmonary autograft in that the main pulmonary artery becomes the neo aorta) and it is no surprise that it also is described following a pulmonary autograft aortic root replacement.23,24 Despite the attractive long-term benefits of providing a patient with a hemodynamically normal aortic valve that does not require anticoagulation, the risk of autograft dilation that may necessitate root replacement (with or without valve sparing techniques) has created caution in recommending the autograft for adult patients.10
Although the pulmonary autograft procedure for aortic valve replacement is a commonly utilized option for children, its use is diminishing in adult-aged patients. One commonly cited concern is the tendency for the pulmonary autograft to dilate in the aortic position. This article reviews a technique we have used in 36 patients since October, 2004 that stabilizes the autograft so that it cannot dilate. There have been no operative or late deaths and the autograft has continued to function in 34 patients. Two patients have undergone autograft replacement because of early failure, which we believe was likely related to technical considerations in our early technique (first reported in the 2005 STCVS Pediatric Cardiac Surgery Annual). The technical modifications described in this article have produced a more reliable and reproducible technique and have not resulted in any autograft failures in our experience. One patient with Marfan’s syndrome and a bicuspid aortic valve is symptom- and dilation-free 8 years post op, with no autograft or pulmonary homograft insufficiency, normal activity and a stable aortic root by serial echocardiography. Our results suggest that this technique might be applicable for selected adult patients in whom autograft growth is not necessary and for whom the risk of autograft dilatation would provide a reason to avoid a pulmonary autograft procedure.
Size and Stiffness of the Pulmonary Autograft after the Ross Procedure in Children
2019, Pediatric Cardiology
Long-term outcomes of the arterial switch operation for transposition of the great arteries and ventricular septal defect and/or aortic arch obstruction
2016, Interactive Cardiovascular and Thoracic Surgery
Dilatation and Dysfunction of the Neo-aortic Root and in 76 Patients After the Ross Procedure
2016, Pediatric Cardiology

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Congenital heart diseaseSimilarities and Differences of the Aortic Root After Arterial Switch and Ross Operation in Children

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Cardiol

J Am Soc Echocardiogr

J Thorac Cardiovasc Surg

Ann Thorac Surg

Congenital heart disease
Similarities and Differences of the Aortic Root After Arterial Switch and Ross Operation in Children