Invited Commentary: More Than 22 Years Later

Aortic Root Replacement in a Patient with Bicuspid Pulmonary Valve Late after Arterial Switch Operation

In this issue of the Thoracic and Cardiovascular Surgeon, Bobylev et al report on “Aortic root replacement in a patient with bicuspid pulmonary valve late after arterial switch operation (ASO).”[1]

It is most gratifying to see patients thrive and do well after complex and sometimes more complicated original neonatal surgery.

Looking at my original operation record (OR) report from our first 3 years' experience of corrective neonatal cardiac surgery in May 1989, both personal and professional memories come up.

The surgical assistants were Zeljko Sutlic and Matthias Karck. Dr. Sutlic is now Professor of Surgery and Head of the Department of Cardiac and Transplantation Surgery at the University Hospital Dubrava, Zagreb, Croatia, and Matthias Karck is now Professor of Surgery and Director of Cardiac Surgery at the University of Heidelberg, Germany.

I also think of my favorite pediatric cardiologists, Ingrid Luhmer, the only one of us who has retired, and Renate Kaulitz, with whom I actually worked with for more than 25 years and would love to continue doing so.

Heinrich was a 4.6 kg neonate, born into a family of farmers in Northern Germany, a day before Ascension Day, a Christian holiday in Germany commonly transformed to Father's Day. As it was routine in those days, Heinrich underwent cardiac catheterization, angiocardiography, and Rashkind balloon atrioseptostomy already during his first few hours of life. Noteworthy was a large, somewhat dilated LV.

Surgery was scheduled for next day at an age of 20 hours, regardless of holiday. Arterial switches in those days were thought to be best done as early as possible. Besides that, on a holiday pediatric surgeons did not interfere with the real surgeons' program. Consequently, secondary chest closure was done 3 days later, Sunday morning in the pediatric intensive care unit.

In the 1980s, Deep Hypothermic Circulatory Arrest (DHCA) was felt to be safe for up to 60 minutes[2]: Heinrich underwent 61 minutes of DHCA, and then we were done, performing a temporary chest wall patch plasty as his heart did not tolerate primary chest closure.

He did not mind any of this. He became a farmer like his father and they continue working together, now Heinrich is 23 years old.

Minor details may be important. The authors wrote that they were surprised to find a bicuspid neoaortic valve. Actually I did not describe it. Were we still too excited in those days? Today, we should have high-end echocardiography, although this is no excuse for an OR report missing important information. I hope all original OR reports will be read before any reoperation.

There is an ongoing discussion how best to treat a failing neoaortic valve after ASO. In their choice of a mechanical valve in this setting, even more so at this age, I completely agree with the authors implanting a mechanical valve.

We reported an incidence of 2.3% for neoaortic valve replacement during a follow-up of up to 18 years in our combined Hannover (1986–1994) and Tuebingen (1994–2004) arterial switch series (n = 176) at our Society's “DACH” meeting in Hamburg 2004.[3] We also, as a “definite” solution, chose mechanical AVR in all four of our own and one patient from the Marie Lannelongue series. Two received valved Carbomedics 23/26 mm composite conduits, 7.2 and 14.9 years after original switch surgery.

Neoaortic valve replacement after ASO is not a routine procedure, but neither is it a genuine problem for congenital cardiac surgeons. However, it takes quite some time and may need more planning than previously thought. Cardiopulmonary bypass times of 5 hours and more are seen and may lead to lower extremity ischemia, when peripheral cannulation has to be chosen. In these cases, intraoperative central recannulation after a time frame not established yet may be indicated. We had to use peripheral arterial cannulation in two of our five patients, choosing the right external iliac artery. The younger the patients are at reoperation, the more they may benefit from pericardial substitutes like polytetrafluoroethylene membranes inserted at original surgery. This makes resternotomy safer, even without peripheral cannulation.

Heinrich, however, underwent his neonatal arterial switch before we routinely employed pericardial membranes. And it still can be guessed where a 2 × 5 cm membrane would have ended up between sternum and heart more than 22 years after implantation and an increase in body weight by a factor of 15 to 20.

My best regards to Lower Saxony, Heinrich and his parents on their farm, and my colleagues in their hospital.

• References

• 1 Bobylev D, Breymann T, Boethig D, Ono M. Aortic root replacement in a patient with bicuspid pulmonary valve late after arterial switch operation. Thorac Cardiovasc Surg 2012; 60
• 2 Ziemer G, Kaulitz R. Neues in der Kinderherzchirurgie. In: Messmer K, Jaehne J, Koenigsrainer A, Suedkamp N, Schroeder W, , eds. Was gibt es Neues in der Chirurgie? Jahresband 2012. Heidelberg, Muenchen: ecomed Medizin; 273-288
• 3 Beierlein W, Salehi-Gilani S, Schneider W, Kaulitz R, Hofbeck M, Ziemer G. Mechanical neo-aortic valve replacement (NAVR) after arterial switch operation. Thorac Cardiovasc Surg 2004; 52: S46