Die Ross-Operation (pulmonaler Autograft) als alternativer Aortenklappenersatz

Hintergrund und Fragestellung: Die Ross-Operation (pulmonaler Autograft) gewinnt seit Ende der 80er Jahre zunehmendes Interesse als Alternative zu herkömmlichen Aortenklappenersatzverfahren. Dargestellt werden die bis zu 12-jährigen Erfahrungen aus einer konsekutiven Serie eines operativen Zentrums.

Patienten und Methodik: Zwischen 1990 und 2002 wurde in einer konsekutiven Serie bei 244 Patienten (190 Männer/ 54 Frauen, mittleres Alter 46 ± 13,5 Jahre) mit Aortenklappenerkrankung eine Ross-Operation, vorwiegend in subkoronarer Operationstechnik, durchgeführt. Die Patienten wurden jährlich klinisch und echokardiographisch nachuntersucht (mittlere Verlaufsbeobachtung bei 99 % der Patienten 32,9 ± 29,5 Monate).

Ergebnisse: Die perioperative Mortalität betrug 0,8 % (n = 2), zwei späte Todesfälle waren auf nicht-klappenassoziierte Ursachen zurückzuführen. Sieben Patienten wurden aufgrund eines Homo- (n = 4) oder Autograftversagens (n = 4) erneut operiert. Nach klinischen Kriterien waren 99 % der nachuntersuchten Patienten im funktionellen Stadium NYHA I und II, nur zwei Patienten mit pulmonaler Komorbidität entsprachen NYHA III. Echokardiographisch wurden über dem Autograft nahezu physiologische Druckgradienten gemessen (maximaler Druckgradient im Mittel 6,5 ± 3,3 mmHg), lediglich bei neun Patienten war eine Aortenklappenregurgitation II. Grades erkennbar. Der maximale transvalvuläre Gradient des Homografts in Pulmonalposition betrug im Mittel 12,0 ± 6,9 mmHg, zehn Patienten hatten eine Pulmonalklappeninsuffizienz II. Grades und ein Patient eine solche III. Grades.

Folgerung: Die technisch anspruchsvolle Ross-Operation weist mittelfristig exzellente klinische und hämodynamische Ergebnisse auf und stellt somit eine attraktive Alternative zu herkömmlichen Aortenklappenersatzverfahren dar. Weitere langfristige Ergebnisse müssen abgewartet werden.

Background and objective: The Ross procedure (pulmonary autograft) has since the 1980s attracted growing interest as an alternative to the widely practised insertion of a prostethic aortic valve. The 12-year experience of a consecutive series from one centre are reported here.

Patients and methods: Between February 1990 and January 2002 a Ross procedure, predominantly with the subcoronary technique, was performed in 244 consecutive patients with aortic valve disease (244 men, 54 women, mean age 46 ± 13.5 years). Annual follow-up clinical examinations (mean postoperative period 32.9 ± 29.5 months in 99 % of the cohort) were performed.

Results: Perioperative mortality was 0.8 % (n=2), and there were two late deaths unrelated to the aortic valve disease. Seven patients had to be re-operated for failure of the homograft (n=4) or autograft (n=4). According to clinical criteria, 99 % of the followed-up patients were in New York Heart Association (NYHA) functional class I or II, only two patients, with pulmonary comorbidity, were in class III. Echocardiography demonstrated autografts with nearly normal transvalvar gradient (mean maximal pressure gradient 6.5 ± 3.3 mmHg), while nine patients had second-degree aortic regurgitation. The mean maximal gradient across the homograft valve in the pulmonary position was 12.0 ± 6.9 mmHg, while ten patients had second-degree and one had third-degree pulmonary regurgitation.

Conclusion: The technically demanding Ross procedure produced excellent clinical and hemodynamic mid-term results. It is thus an appealing alternative to the widely used replacement by a prosthetic valve. Definitive assessment awaits further long-term follow-up.

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