Abstract OBJECTIVE: To compare the clinical outcomes of McGoon’s method with Doty’s method for the correction of supra-aortic stenosis. METHODS: 80 cases of SVAS were treated surgically from October 1996 to October 2008, and 58 patients were enrolled in this study. Among them, 35 cases were in the McGoon method correction group and 23 cases were in the Doty method correction group. The differences in intraoperative extracorporeal circulation time, ascending aortic block time, postoperative thoracic drainage, aortic left ventricular pressure difference, incidence of aortic valve closure insufficiency and postoperative long-term aortic left ventricular pressure difference, incidence of aortic valve closure insufficiency were analyzed and compared between the two groups. Results There was no significant difference in the intraoperative extracorporeal circulation time, ascending aortic block time, postoperative thoracic drainage flow, aortic left ventricular pressure difference, and incidence of aortic valve closure insufficiency between the two groups (P>0.05). The follow-up time was (4.0±3.5) and (4.5±4.2) years in the two groups, respectively. During the follow-up period, there were no reoperation cases or deaths; there was no significant difference in the aortic left ventricular pressure difference and the incidence of aortic valve closure insufficiency between the two groups (P>0.05). CONCLUSION: Both McGoon’s method and Doty’s method for the correction of supra-aortic stenosis can achieve satisfactory immediate and long-term clinical results. Keywords: supra-aortic stenosis; comparative study; surgery Supra-aortic stenosis (SVAS) is a congenital heart disease characterized by stenosis of the ascending aorta at the superior border of the sinus of Valsalva, which can be an important manifestation of Williams syndrome in the cardiovascular system, or a familial or disseminated case. Currently, McGoon’s method and Doty’s method are the most commonly used methods of correction. From October 1996 to October 2008, 80 cases of SVAS were treated surgically at Fu Wai Hospital for Cardiovascular Diseases. In order to compare the effects of surgical treatment between McGoon’s method and Doty’s method, a comparative study was conducted on the 58 patients enrolled in the study, which is now reported as follows. 1. Data and methods 1.1 Selection and grouping of cases From October 1996 to October 2008, 80 cases of SVAS were treated surgically, of which 8 cases were combined with diffuse stenosis of the ascending aorta and 8 cases underwent ascending aortoplasty during the same period of time; 9 cases were combined with bicuspid aortic valve deformity, of which 3 cases underwent Ross surgery, 2 cases underwent aortoplasty and 4 cases underwent aortic valve replacement; 4 cases were combined with hypertrophic obstructive cardiomyopathy and 4 cases were combined with left ventricular outflow from the left ventricle. One case of hypertrophic obstructive cardiomyopathy underwent left ventricular outflow tract unblocking; one case of combined aortic constriction underwent ascending aorta to abdominal aorta artificial vascular bypass grafting; and three cases of limited SVAS underwent correction by Brom’s method. These concomitant surgeries or combined malformations would have affected the outcome of McGoon’s method compared with Doty’s method and were therefore not included. In addition, the Brom method was not included. Of the 58 patients enrolled, 35 were McGoon method (Group M) and 23 were Doty method (Group D). 1.2 General information All 58 patients in this group underwent echocardiography. Among them, 34 patients were definitively diagnosed by echocardiography, 19 patients were definitively diagnosed with the aid of CT or MRI, and 5 patients were definitively diagnosed with the aid of ascending aortography and selective pulmonary arteriography. In all cases, the pressure difference from the left ventricle to the ascending aorta was determined by Doppler ultrasound. 1.3 Surgical methods The ascending aorta was cannulated into the superior and inferior vena cava to establish extracorporeal circulation. After the aortic root was perfused with cold myocardial protection fluid, an oblique incision was made in the ascending aorta.McGoon’s method was used to correct the group: the lower end of the incision was extended toward the coronary sinus of the aortic valve, over the stenotic ring, and up to the sinotubular junction. Patch material was taken, trimmed into a tear-drop shape, and aortic dilatation angioplasty was performed.Doty’s method: the lower end of the incision was extended to the right coronary sinus of the aorta and the coronary sinus without coronary artery, respectively, and both of them crossed the stenotic ring to the sinotubular junction. The patch material was trimmed to a breeches shape and aortic enlargement plasty was performed. Patch materials in both groups included polyester vascular sheets, Gore-tex vascular sheets, fresh or glutaraldehyde-fixed autologous pericardium and homograft vascular sheets. 1.4 Observation indexes Intraoperative extracorporeal circulation time, ascending aortic block time, postoperative thoracic drainage, aortic left ventricular pressure difference before discharge, and incidence of aortic valve closure insufficiency. Incidence of aortic left ventricular pressure difference and aortic valve closure insufficiency during the follow-up period. 1.5 Statistical processing Statistical methods used were t-test and chi-square test. The relevant data were expressed as mean ± standard deviation. 2, Results The preoperative data of the two groups, including cardiothoracic ratio, left ventricular ejection fraction, aortic left ventricular pressure difference, and combined pulmonary stenosis were not significantly different, P>0.05. Although the mean value of intraoperative ascending aortic block time of group M was greater than that of group D, there was no significant difference between the two groups in the statistical test, P>0.05. Postoperative thoracic drainage flow, assisted respiration time, secondary chest opening rate, aortic left ventricular pressure difference, aortic valve closure insufficiency rate before discharge, and aortic valve closure insufficiency rate. Differential pressure, and incidence of aortic valve closure insufficiency were statistically tested to be not significantly different between the two groups, P>0.05. One case died in group M, from right ventricular overload and right heart insufficiency. There was one patient in each group due to anastomotic hemorrhage, and chest closure was postponed after intraoperative gauze compression for hemostasis.One patient in group D underwent postoperative diaphragmatic folding for right-sided diaphragmatic paralysis. The follow-up time was (4.0±3.5) years and (4.5±4.2) years for the two groups, respectively. During the follow-up period, there were no reoperation cases or deaths; there was no significant difference in the incidence of aortic left ventricular pressure difference and aortic valve closure insufficiency between the two groups (P>0.05). DISCUSSION In 1961, McGoon first used tear-drop artificial vascular patch to perform aortic expansion angioplasty to treat SVAS successfully. Subsequently, this method was widely used in clinical practice and is still used by many surgeons.Although McGoon’s method relieved the obstruction on the aortic valve, the morphology of the aortic root did not return to normal, and postoperative stenosis may be residual or result in incomplete closure of the aortic valve.In 1977, Doty applied the breeches-like patch with the incision extended to the right coronary sinus of the aorta and the aortic coronary sinus-free Although there is no lack of reports on surgical treatment of SVAS in the literature, because SVAS is relatively rare in clinical practice, there is a lack of comparative studies in the literature on the clinical outcomes of the McGoon method and the Doty method. From the results of this comparison, it can be seen that there was no significant difference in the preoperative cardiothoracic ratio, left ventricular ejection fraction, aortic left ventricular pressure difference, and combined pulmonary stenosis between the two groups. Although the mean value of intraoperative ascending aortic block time in group M was greater than that in group D, there was no significant difference between the two groups, and there were no special difficulties in surgical technique except that the right coronary opening should not be injured when the incision was extended to the right coronary sinus of the aorta in Doty’s method. Although the Doty method was slightly more complicated than the McGoon method, there was no significant difference in the amount of postoperative bleeding, assisted respiration time, and the rate of secondary hemostasis between the two groups. Theoretically, the Doty method enabled the morphology of the aortic root to be closer to normal than the McGoon method, but the incidence of aortic left ventricular pressure difference and the occurrence of aortic valve closure insufficiency before the patients were discharged from the hospital did not differ significantly between the two groups in the statistical test. Therefore, we concluded that there was no difference in recent clinical outcomes between the two correction methods. Limited to the change in communication tools and the urbanization of the country, very few patients came to the hospital for follow-up on their own initiative, and a significant number of patients were lost to follow-up. Although the follow-up rates of the two groups were not high, the information obtained from the follow-up showed that there was also no significant difference between the two groups in terms of long-term aortic left ventricular pressure difference and the incidence of aortic valve closure insufficiency. Therefore, we believe that the McGoon correction method is easier and more feasible for patients with less localized SVAS lesions. For patients with more localized SVAS requiring aortic root contouring, the Doty correction method is more reasonable. After postoperative cardioversion, if right ventricular overload and right heart insufficiency are found, the presence of pulmonary stenosis, especially the presence of stenosis of the internal pulmonary artery, should be considered. Therefore the diagnosis must be clarified preoperatively. When echocardiography is not clear, the diagnosis should be clarified by CT or cardiography.One patient in group M died of right ventricular overload and right heart failure, which was importantly attributed to the failure to diagnose extensive pulmonary artery stenosis preoperatively. Bleeding is an important complication after SVAS correction. One patient in each of the two groups (in early life) had difficulty in stopping intraoperative bleeding, which was stopped by gauze compression and recovered after postponed closure of the chest. The incidence of micro or mild aortic valve closure insufficiency in the early postoperative period after correction of SVAS by McGoon’s method versus Doty’s method was low in our group, 11.4% and 8.7%, respectively, which was significantly lower than that reported in the literature and may be related to the type and size of the patch material. Patch material may affect the long-term outcome after surgery, especially in pediatric patients. As children’s bodies grow, patch material that cannot grow may cause twisting and deformation of the aortic root, leading to recurrence of SVAS and aortic valve closure insufficiency. Due to the dispersed types of patch materials used in this group, it is not possible to compare the long-term results of different patch materials. We believe that the patch material should be selected intraoperatively based on the thickness of the patient’s aortic wall and the pliability of the material. The materials selected in our group included polyester vascular patches, Gore-tex vascular patches, fresh or glutaraldehyde-fixed autologous pericardium and homograft vascular patches. The main reason for reoperation after SVAS has been reported in the literature as aortic valve diastasis deformity. There were no cases of reoperation during the follow-up period in our group, and one of the important reasons was that cases with combined aortic valve diastolic malformation were excluded from this study.