Home » 2009 » Number 09-10: An unusual complication of the Ross procedure and the role of CMR in its assessment

Number 09-10:  An unusual complication of the Ross procedure and the role of CMR in its assessment

From: Nigel J Artis¹ MD, Sven Plein^1,2 MD, John P Greenwood^1,2 MD
Institution: ¹Department of Cardiology, Leeds General Infirmary; ²Division of Cardiovascular and Neuronal Remodelling, University of Leeds, Leeds, UK

***This case (09-10) and the next one (09-11) represent a short case series on the role of CMR to assess different complications of the Ross procedure.

Clinical history: A 26 year old male had previously undergone a Ross procedure¹ for a stenosed bicuspid aortic valve when aged 17yrs. At routine follow-up, transthoracic echocardiography showed a right ventricular outflow tract gradient of 60mmHg, but could not elucidate the cause.  CMR identified a large (3cm x 5cm) false aneurysm at the proximal neo-aortic valve suture line causing dynamic obstruction of the main pulmonary artery. The left main stem was also shown to be compressed.  He subsequently underwent repair of the aneurysm and made a full recovery.                                                                                        

Movie 1

Movie 2

Cine CMR : LVOT SSFP cine images (Movie 1) demonstrated the dehiscence at the proximal neo-aortic valve suture line and the associated pseudo-aneurysm (red arrow). Also note the degree of aortic incompetence. RVOT SSFP cine images (Movie 2) showed the mildly incompetent pulmonary valve and the dynamic obstruction that the aneurysm caused (white arrow).

Flow CMR: Magnitude and phase contrast velocity mapping (Movie 3, right and left images, respectively) of the aortic flow (Q) showing mild aortic regurgitation with a regurgitant fraction of 16%.Phase contrast velocity mapping (Movie 4, right and left images, respectively) of the pulmonary flow (P) showing peak RVOT velocity of 4.0ms^-1 with a regurgitant fraction of 23%.      

Movie 3

Movie 4

Movie 5

A SSFP cine image at the level of the great vessels (Movie 5) showed the left main stem coronary artery lying between (and compressed by) the false aneurysm and the main pulmonary artery (black arrow).  

Perspective: CMR is the imaging modality of choice for long term serial assessment following the Ross procedure. CMR was able to accurately define the anatomy of this rare complication and aid surgical planning.

References:

1. Puranik R, Tsang V, Broadley A, Nordmeyer J, Lurz P, Muthialu N, Graham D, Walker F, Cullen S, de Leval M, Bonhoeffer P, Taylor A, Muthurangu V. Functional Outcomes After the Ross (Pulmonary Autograft) Procedure assessed with Magnetic Resonance Imaging and Cardiopulmonary exercise testing. Heart 2009 In press.

2. Crowe ME, Rocha CA, Wu E, Carr JC. Complications following the Ross procedure: cardiac MRI findings. J Thorac Imaging 2006;21:213-8.

3. Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet. 1967; 2: 956-959.

 

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• Mon, 07 Feb 2011 15:57
  
  Very nice case.
  
  Regarding the question of coronary artry compression between the PA and the Aorta, I always wonder if a coronary artery can really be compressed between the PA and Aorta.
  
  A coronary artery has more or less the same pressure as the Aorta and mostly more pressure than the PA. Therefore the coronary artery should usually dent into the PA (assuming no calcification etc.) and not be compressed by the two vessels. In this case (movie 5) it dents into the aneurysm.
  
  Accordingly, I assume that in these cases the symptoms are not caused by the coronary artery being compressed but more likely being kinked at the origin from the Aorta.
  
  What do others think?...