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Interact CardioVasc Thorac Surg 2009;9:545-546. doi:10.1510/icvts.2009.203067 © 2009 European Association of Cardio-Thoracic Surgery
Minimally invasive Ross procedure through partial upper sternotomyDepartment of Cardiac and Vascular Surgery, Robert Bosch Hospital, Auerbachstr. 110, D-70376, Stuttgart, Germany Received 26 January 2009; received in revised form 16 April 2009; accepted 20 April 2009
*Corresponding author. Tel.: +49-711-8101-3650; fax: +49-711-8101-3798.
The Ross procedure has gained increasing interest for therapy of aortic valve pathologies in young adults because of excellent long-term results. This case report describes the first published experiences of the Ross procedure performed through a minimally invasive access in two consecutive patients. The limited access is associated with only a slightly prolonged aortic cross-clamp time. Consequently, a minimal access method does not result in an increased risk for patients.
Key Words: Aortic valve replacement; Minimal invasive surgery; Surgical technique For patients younger than 65 years old, mechanical prostheses are recommended [1]. However, these prostheses demonstrate an incidence of severe, valve-related, adverse events of 2–5% per year. The Ross procedure, characterized by the replacement of the diseased aortic valve with the pulmonary autograft, and the transplantation of a pulmonary homograft in the pulmonary valve position, has gained increasing interest for therapy of aortic valve pathologies in adults [2]. Postoperative anticoagulation is not required. Long-term results are excellent, with stable function of both the aortic and pulmonary valves, and a low incidence of valve-related complications [3–5]. Minimally invasive access to the aortic valve, through partial sternotomy, allows for better postoperative recovery of the patient, due to higher stability of the thorax and better conservation of the lung function [6, 7]. A superior cosmetic result compared to the complete sternotomy, has increasing importance, especially for young patients. However, no reports exist regarding the application of this access method to technically more complex procedures. Here, we report our initial experiences of the Ross procedure, through a partial upper sternotomy, in the first two consecutive patients. A 30-year-old male patient had suffered from chronic ulcerous colitis since 1996. The preoperative diagnostics confirmed a bicuspid valve with leading insufficiency. The left ventricular ejection fraction was reduced slightly to 57%. The second patient, a 51-year-old female, was deeply interested in an optimal cosmetic result. The body mass index of the patients measured 23 and 25, respectively. For the procedure, we used our standard access for minimally invasive aortic valve surgery. Through a 6 cm skin incision, starting at the sternal angulus (Fig. 1), the partial upper L-shape sternotomy was performed using an oscillating saw. The sternum was opened at the midline, down to the fourth right intercostal space, sparing the right internal mammarian artery. A flat two-stage venous canula (Medtronic®, Düsseldorf, Germany) was inserted through a separate subxyphoideal skin incision, pulled up retrosternally and pre-pericardially, and putted in place through the right auriculum. Aortic canula was placed into the distal ascending aorta and led out through the main access as well as the aortic cross-clamp. The Ross procedure was executed using the root replacement technique. Compared to our standard procedure, the pulmonary homograft was implanted after implantation of the autograft in the aortic annulus. At this time, the homograft was placed through the aortic annulus into the left ventricular outflow tract. The knotted suture next to the pulmonary valve can be used to move the right ventricular outflow tract onto the left side, if necessary. For autograft implantation, interrupted sutures were applied encircling a continuous Teflon strip to ensure prophylaxis of subsequent annular dilation. All other anastomoses were performed using continuous sutures (Fig. 2). Aortic cross-clamp times were 153 min and 142 min, and the total bypass times were 183 min and 170 min, respectively. For myocardial protection, Brettschneider's HTK-solution (Custodiol®, Köhler–Chemie, Ansbach, Germany) was initially administered at 2000 ml via aortic root, and later at 1000 ml through coronary ostia, after 90 min of cardiac arrest. Pulmonary homografts were supplied by the German Society for Tissue Transplantation (DGfG, Hannover, Germany).
Postoperatively, patients were ventilated for 5 h. Time spent in the intensive care unit was 1 day. Admission was recorded on postoperative days 8 and 5, respectively. In both patients, there was no echocardiographic evidence for regurgitation at either the aortic or pulmonary valves, correspondingly. The mean gradients confirmed at the aortic valve were 3 and 6 mmHg respectively. There was no gradient at the pulmonary valve in both patients. The overall cosmetic result was considered excellent (Fig. 1). We conclude that the Ross procedure can be performed technically, through minimally invasive access, in patients with typical anatomy and body mass index. This limited access is associated with only a slightly prolonged aortic cross-clamp time. In case of complications, the transformation to a complete sternotomy can be performed at every stage of procedure. Consequently, the minimal access method does not result in an increased risk to patients.
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