Reddy V M, McElhinney D B, Phoon C K, Brook M M, Hanley F L
Division of Cardiothoracic Surgery, University of California, San Francisco, USA.
J Thorac Cardiovasc Surg. 1998 Jun;115(6):1255-62; discussion 1262-3. doi: 10.1016/S0022-5223(98)70207-7.
There is often substantial mismatch between the diameters of the pulmonary and aortic anuli in young patients with systemic outflow tract disease. To implant the autologous pulmonary valve in the aortic position under such circumstances, it is necessary to adapt the geometry of the systemic outflow tract. The effects of such adaptations on autograft function in children are not well known.
To determine factors predictive of autograft regurgitation, we analyzed 41 cases of children who have undergone the Ross procedure. The diameter of the pulmonary valve was greater (by at least 3 mm) than that of the aortic valve in 20 cases, equal (within 2 mm) in 12 cases, and less (by at least 3 mm) in nine cases, with differences ranging from +10 to -12 mm. In 12 patients with a larger pulmonary anulus, aortoventriculoplasty was used to correct the mismatch. In patients with a larger aortic anulus, the mismatch was corrected by gradual adjustment along the circumference of the autograft, rather than by tailoring of the native aortic anulus.
At follow-up (median 31 months), two patients had undergone reoperation on the neoaortic valve for moderate regurgitation. In the remaining 38 cases, autograft regurgitation was as follows: none or trivial in 30, mild in seven, and moderate in one. There was no correlation between regurgitation and age, geometric mismatch, or previous or concurrent procedures.
Subtle technical factors that may result in distortion of the valve complex are probably more important determinants of autograft regurgitation than are indication for repair, geometric mismatch, or previous or concomitant outflow tract procedures. Significant mismatch of the semilunar anuli is not a contraindication to the Ross procedure in children.
患有体循环流出道疾病的年轻患者，其肺动脉瓣环和主动脉瓣环的直径常常存在明显不匹配。在这种情况下，要将自体肺动脉瓣植入主动脉位置，就必须调整体循环流出道的几何形状。而这种调整对儿童自体移植瓣膜功能的影响尚不明确。
为了确定预测自体移植瓣膜反流的因素，我们分析了41例接受罗斯手术的儿童病例。其中20例肺动脉瓣直径大于主动脉瓣直径（至少大3毫米），12例两者相等（相差在2毫米以内），9例肺动脉瓣直径小于主动脉瓣直径（至少小3毫米），差值范围为+10至-12毫米。对于12例肺动脉瓣环较大的患者，采用主动脉心室成形术来纠正不匹配。对于主动脉瓣环较大的患者，通过沿自体移植瓣膜的圆周逐渐调整来纠正不匹配，而不是对天然主动脉瓣环进行裁剪。
在随访（中位时间31个月）时，有2例患者因中度反流接受了新主动脉瓣再次手术。在其余38例病例中，自体移植瓣膜反流情况如下：30例无反流或微量反流，7例轻度反流，1例中度反流。反流与年龄、几何形状不匹配或既往或同期手术之间无相关性。
可能导致瓣膜复合体变形的细微技术因素，可能比修复指征、几何形状不匹配或既往或同期流出道手术更能决定自体移植瓣膜反流。半月瓣环的明显不匹配并非儿童罗斯手术的禁忌证。
