Use of the pulmonary autograft for mitral replacement: short- and medium-term experience
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Objectives: In an effort to find a suitable mitral substitute for our young rheumatic patients who cannot follow a proper anticoagulation regimen for life, we resorted to an old concept reported by one of the authors (D.N.R.) in 1967. This report summarizes our experience with the Ross-mitral operation to date. Methods: Between 19 June 1997 and 27 June 2000, 43 patients with rheumatic valve disease underwent the Ross-mitral operation. Two patients were excluded because of graft stenosis detected at the end of the procedure for which the autograft had to be sacrificed. Of the remaining 41 patients 29 were female, and the age range was 12–57 years (median 39 years). The autograft was incorporated within a Dacron tubing, with a pericardial collar attached to its proximal end. The conduit was sutured distally to the excised mitral annulus; the pericardium was attached proximally to the atrial wall in 36 patients, and was used simply to cover the Dacron tubing in five patients. The pulmonary artery was replaced with a pulmonary or aortic homograft, or with a pulmonary xenograft. Results: There were two hospital fatalities from a cerebrovascular accident and a lung injury, and two postoperative myocardial infarctions. There were five late deaths, two due to bacterial endocarditis, one due to excessive bleeding at reoperation for a paravalvular leak, and two not related to the procedure. A phenomenon of ‘autograft stenosis’ occurred intraoperatively in four recent consecutive patients that probably resulted from our use, for the first time, of softer Dacron tubing material. This was repaired in two of the four patients. Echocardiography confirmed excellent functioning of all 34 autografts of surviving patients up to 36 months postoperatively (mean follow-up 18.2 months). Two patients remain in functional Class III status, one due to left heart failure following myocardial infarction, and the other due to recurrent tricuspid insufficiency. Conclusions: We believe that the mitral pulmonary autograft is a worthwhile alternative to mechanical prostheses in developing countries.