Knott-Craig Christopher J, Goldberg Steven P, Pastuszko Peter, Peyton Marvin D, Kirklin James K
University of Oklahoma Health Sciences Center, Department of Thoracic and Cardiovascular Surgery, Oklahoma, USA.
J Heart Valve Dis. 2007 Jul;16(4):394-7.
Progressive pulmonary autograft dilatation and failure following a Ross operation continues to be of major concern. It is hypothesized that the pulmonary autograft may perform better over the longer follow up period if the Ross operation is performed as a reoperation rather than a primary operation. The basis for this hypothesis is that the epicardial and mediastinal fibrosis encountered at reoperation may inadvertently provide additional support for the pulmonary autograft during the follow up period.
To test this hypothesis, 281 patients (mean age 24 +/- 9 years) who underwent a Ross operation over a 16-year period were retrospectively analyzed. The patient population was divided into two subgroups in whom the Ross operation was performed: (i) as the first cardiac operation, through a sternotomy incision (primary-Ross; n = 180); and (ii) after the patient had undergone a previous sternotomy (prior-sternotomy; n = 101). A recent follow up examination was achieved in 93% of patients.
Early and overall mortality was 2.1% and 6.4%, respectively, and there was no significant difference between the subgroups. At 12-year follow up, freedom from reoperation on the autograft, or valve-related death was 87 +/- 6% versus 71 +/- 9% in favor of the prior-sternotomy subgroup (p = 0.06). At 12-year follow up, freedom from valve-related death, or reoperation on the pulmonary autograft, or severe aortic regurgitation was 87 +/- 5% versus 71 +/- 7% (p = 0.03) in favor of the prior-sternotomy subgroup.
The results of a preliminary analysis suggest that additional benefit is accrued when the Ross operation is performed during re-sternotomy. This should encourage surgeons to attempt repair of the aortic valve during the initial surgery, with the knowledge that - if needed - the Ross operation can be performed safely at later surgery, and with possible additional benefit to the patient during the follow up period.
Ross手术后自体肺动脉瓣逐渐扩张及功能衰竭仍是主要关注问题。有假说认为，若Ross手术作为再次手术而非初次手术进行，自体肺动脉瓣在更长随访期内可能表现更佳。该假说的依据是，再次手术时遇到的心外膜和纵隔纤维化可能在随访期内无意中为自体肺动脉瓣提供额外支撑。
为验证该假说，对16年间接受Ross手术的281例患者（平均年龄24±9岁）进行回顾性分析。患者群体分为接受Ross手术的两个亚组：（i）作为首次心脏手术，经胸骨切开术切口进行（初次Ross手术；n = 180）；（ii）患者先前已接受胸骨切开术后进行（先前胸骨切开术；n = 101）。93%的患者获得了近期随访检查。
早期死亡率和总死亡率分别为2.1%和6.4%，亚组间无显著差异。在12年随访时，自体肺动脉瓣无需再次手术或无瓣膜相关死亡的比例，先前胸骨切开术亚组为87±6%，初次Ross手术亚组为71±9%（p = 0.06）。在12年随访时，无瓣膜相关死亡、无需对自体肺动脉瓣再次手术或无严重主动脉瓣反流的比例，先前胸骨切开术亚组为87±5%，初次Ross手术亚组为71±7%（p = 0.03），先前胸骨切开术亚组更优。
初步分析结果表明，再次胸骨切开术时进行Ross手术会带来额外益处。这应促使外科医生在初次手术时尝试修复主动脉瓣，因为他们知道——如有需要——Ross手术可在后续手术中安全进行，且在随访期内可能给患者带来额外益处。
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