European Heart Journal Advance Access originally published online on July 22, 2008
European Heart Journal 2008 29(17):2181-2182; doi:10.1093/eurheartj/ehn289
Is the Ross procedure really a Trojan horse: reply
Department of Cardio-Thoracic Surgery, Bd 577
Erasmus University Medical Center Rotterdam
PO Box 2040
3000 CA Rotterdam
The Netherlands
Department of Cardio-Thoracic Surgery, Bd 577
Erasmus University Medical Center Rotterdam
PO Box 2040
3000 CA Rotterdam
The Netherlands
Department of Cardio-Thoracic Surgery, Bd 577
Erasmus University Medical Center Rotterdam
PO Box 2040
3000 CA Rotterdam
The Netherlands
Email: l.klieverik{at}erasmusmc.nl
We thank Dr Dohmen et al. for their critical and culturally enriching letter regarding our paper entitled ‘The Ross procedure: A Trojan Horse?’ We congratulate the authors with their extensive experience and look forward to the first report on their results with this impressive patient population.
The modern speculations of the Trojan Horse that Dohmen et al. describe in their letter are not the most obvious explanation to the myth. The well-known common myth of the Trojan Horse is the myth of the giant wooden horse, a gift for Pallas Athena. This horse was hollow and contained Greek soldiers who overtook the city of Troy during the Trojan War (http://en.wikipedia.org/wiki/Trojan_War). This myth has become the common metaphor for anything that appears innocent or benign, but actually presents with unpleasant consequences.
The Ross operation is the only aortic valve operation that provides the patient with a living valve substitute, a truly wonderful gift. Yet, there is accumulating evidence that over time the durability of the Ross procedure may be disappointing, as is illustrated in the Trojan horse paper on our own experience. In Rotterdam, we find that the durability of the Ross operation is comparable with other biological valve substitutes.1 However, we do not conclude in our paper that the Ross operation is a Trojan Horse, but critically assess the operation in our own experience. The question mark in the title of our paper is illustrative of this critical assessment.
Dr Dohmen et al. refer to the experience of Dr Kouchoukos et al.2 as being an example of excellent results with the Ross operation. However, Kouchoukos's paper actually represents the first landmark report of disappointing autograft re-operation rates (75% freedom from autograft reoperation at 10 years). On the other hand, Dr Dohmen et al. are correct that for rheumatic heart valve disease patients in developing countries with limited access to anticoagulation therapy, there is surely a great advantage to the use of the Ross procedure. Also, the employment of the subcoronary implantation technique may, in experienced hands,3 provide a better autograft durability.
With regard to valve-related complications other than non-structural and structural valve failure,4 the Ross procedure does provide the patient with a superior valve substitute compared with mechanical and biological valve substitutes. The debate remains whether the excellent survival observed in Ross patients can be attributed to the haemodynamically superior valve and low valve-related complication rates, or whether it is due patient selection. We have thus far been unable to prove this.5
Unfortunately, we are yet unable to answer Dr Dohmen's question: is the Ross procedure really a Trojan Horse? There is a need to combine forces, and critically assess and define the factors that may potentially improve durability (like uniformly applied implantation techniques, postoperative antihypertensive treatment) of this very special operation, in order to perfect the ingenious concept that Donald Ross invented more than 40 years ago.
References
- Klieverik LM, Bekkers JA, Roos JW, Eijkemans MJ, Raap GB, Bogers AJ, Takkenberg JJ. Autograft or allograft aortic valve replacement in young adult patients with congenital aortic valve disease. Eur Heart J (2008) 29:1446–1453.
[Abstract/Free Full Text] - Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Davila-Roman VG. The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg (2004) 78:773–781. discussion 773–781.
[Abstract/Free Full Text] - Willems TP, Takkenberg JJ, Steyerberg EW, Kleyburg-Linkers VE, Roelandt JR, Bos E, van Herwerden LA. Human tissue valves in aortic position: determinants of reoperation and valve regurgitation. Circulation (2001) 103:1515–1521.
[Abstract/Free Full Text] - Akins CW, Miller DC, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL, Takkenberg JJ, David TE, Butchart EG, Adams DH, Shahian DM, Hagl S, Mayer JE, Lytle BW. Guidelines for reporting mortality and morbidity after cardiac valve interventions. J Thorac Cardiovasc Surg (2008) 135:732–738.
[Free Full Text] - Klieverik LM, Noorlander M, Takkenberg JJ, Kappetein AP, Bekkers JA, van Herwerden LA, Bogers AJ. Outcome after aortic valve replacement in young adults: is patient profile more important than prosthesis type? J Heart Valve Dis (2006) 15:479–487. discussion 487.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||