Is age or root size the decision factor for reinforced aortic root replacement (Reinforced Ross operation) in the pediatric population?

The root enlargement depend abotu the type of BAV (Typ 3 or root fenotype). We do not prefere Ross procedure becaus we believe in theory that bicuspid aortopathy belong to conotruncal anomalies. There are no criteria for operation in young children, but we believ it is necessary to treat LVOTO and enlargement of differnt types of aortic dilatation, including the root of aorta and CoA with the methods wihout Ross operation. This is the way for the tretment only one "valve", not two valves. it is necessary in paediatric age to develop the metods without Ross procedure. We beklieve in new methods with more currage, like Ozaka op.

Best regards, I.Malčić

Francesco Nappi

The pulmonary autograft is the ideal substitute for aortic valve disease in children and young adult. Accumulating evidence suggest that the advantages of the pulmonary autograft are represented by acceptance to the same self-biological, an absent immune and inflammatory responses, the ability of the growing pulmonary autograft to match the somatic growth and the avoidance of life-long anticoagulation. In adult population, the use of pulmonary autograft is indicated for surgical treatment of bicuspid aortic valve that is the most common congenital heart defect affecting 1,3% of the population worldwide. The disadvantage of the pulmonary autograft implanted in aortic position is the dilatation process when it is subjected to systemic-pressure load.

However, observations elegantly discussed by Horer et al. concerning the differential potential of dilation at the various segments of the aorta, i.e. annulus, Valsalva sinuses (0,5 mm/year) and sinutubular junction (increase of 0,7-0,9 mm/year), outlined the need to tailor mechanical features of PA reinforcements in their different parts. This induced to reconsider their design with the aim to better adapt to the normal physiology of the aortic root improving the resistance of the zones, which are meant to majorly suffer from dilatative degeneration. In the context of Ross procedure the potential of dilation of Valsalva sinuses is a pivotal problem as it might affect the status of the reimplanted coronaries. Additionally, mechanical stress associated to progressive overstrain of the graft under systemic pressure might affect PA integrity and the endothelialization process16; therefore in this context prevention of graft stretching is crucial.

Previous experience with a prosthetic Dacron graft with an artificial aortic root configuration (Valsalva graft) as external reinforcement of the PA has been reported by Carrel et al. This approach was attempted with the aim to to prevent neoaortic root dilatation and prevent the dynamic function of Valsalva sinuses. Surely, this techique would carry the advantage graft to allow the most physiologic pressure and flow patterns within the autograft in respect to a straight Dacron graft. Indeed the autograft encased in a straight Dacron prosthetic graft would be dramatically impaired in its pulsatility and compliance. Moreover, we previously demonstrated as Dacron graft and other synthetic polyesters severely impair aortic compliance when used as vascular replacement16 and elicit a strong inflammatory reaction with significant damage to vessel wall when used a PA reinforcement1. From these standpoints we focused in improving the biomechanical behaviour of the reinforced PA using a composite biodegradable and auxetic material.

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