Raanani E, Yau T M, David T E, Dellgren G, Sonnenberg B D, Omran A
Toronto General Hospital, University Health Network, Department of Surgery, University of Toronto, Ontario, Canada.
Ann Thorac Surg. 2000 Dec;70(6):1953-7. doi: 10.1016/s0003-4975(00)01905-6.
We reviewed our experience with the Ross procedure to identify the prevalence and predictors of late pulmonary homograft stenosis.
Between June 1992 and December 1997, 109 consecutive patients (age 34.5 +/- 8.6 years) underwent the Ross procedure, with reconstruction of the right ventricular outflow tract with a cryopreserved pulmonary homograft (22 to 30 mm diameter). There was one early and one late death. Echocardiographic follow-up was available in 105 of 108 patients (97%), with a follow-up of 39 +/- 20 months. Homograft donor and preservation measurements and patient variables were subjected to multivariable analyses to identify independent predictors of late homograft performance.
The major physiopathologic finding was homograft stenosis. Peak systolic gradients across the homograft were 20 mm Hg or more in 30 of 105 patients (28.5%) and 40 mm Hg or more in 4 of 105 patients (3.8%). One patient required two re-replacements of her homograft for severe stenosis. Moderate or severe homograft insufficiency was noted in 10 of 105 patients (9.5%). The independent predictors of late pulmonary homograft stenosis were younger donor age (p = 0.03), shorter duration of cryopreservation (p = 0.01), and smaller homograft size (p = 0.06). Beating heart donor status, short homograft ischemic time, and other factors that have been shown to be associated with increased graft viability were associated with graft stenosis but did not reach statistical significance. However, mean gradients across the homograft were significantly related (p = 0.002) to the number of these risk factors in each patient.
Stenosis of the pulmonary homograft can be a significant problem following the Ross procedure, and was predicted by younger donor age and shorter duration of cryopreservation. These factors may be related to increased cellular viability, which might actually predispose to late homograft stenosis in a subgroup of patients.
我们回顾了我们在罗斯手术方面的经验，以确定晚期肺动脉同种异体移植狭窄的发生率及预测因素。
在1992年6月至1997年12月期间，109例连续患者（年龄34.5±8.6岁）接受了罗斯手术，采用冷冻保存的肺动脉同种异体移植物（直径22至30毫米）重建右心室流出道。有1例早期死亡和1例晚期死亡。108例患者中的105例（97%）有超声心动图随访，随访时间为39±20个月。对同种异体移植物供体和保存测量指标以及患者变量进行多变量分析，以确定晚期同种异体移植物功能的独立预测因素。
主要的病理生理发现是同种异体移植狭窄。105例患者中有30例（28.5%）同种异体移植物的收缩期峰值梯度为20毫米汞柱或更高，105例患者中有4例（3.8%）为40毫米汞柱或更高。1例患者因严重狭窄需要两次重新更换同种异体移植物。105例患者中有10例（9.5%）出现中度或重度同种异体移植功能不全。晚期肺动脉同种异体移植狭窄的独立预测因素是供体年龄较小（p = 0.03）、冷冻保存时间较短（p = 0.01）和同种异体移植物尺寸较小（p = 0.06）。心脏跳动供体状态、同种异体移植物缺血时间短以及其他已被证明与移植物活力增加相关的因素与移植物狭窄相关，但未达到统计学意义。然而，同种异体移植物的平均梯度与每位患者这些危险因素的数量显著相关（p = 0.002）。
肺动脉同种异体移植狭窄可能是罗斯手术后的一个重要问题，且可通过供体年龄较小和冷冻保存时间较短来预测。这些因素可能与细胞活力增加有关，这实际上可能使一部分患者易发生晚期同种异体移植狭窄。
