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Varrica A, Giamberti A, Lo Rito M, Reali M, Hafdhullah M, Satriano A, Saracino A, Micheletti A, Frigiola A. Ross Operation in Pediatric Population: Impact of the Surgical Timing and the Native Pulmonary Diameter on the Outcome. Pediatr Cardiol 2023; 44:663-673. [PMID: 35994068 DOI: 10.1007/s00246-022-02990-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/09/2022] [Indexed: 11/24/2022]
Abstract
Aortic valve replacement early in life may be inevitable. Ross operation, until present day, remains the favorite surgical option in pediatrics with irreparable aortic valve disease. Nonetheless, the necessity for re-operation was always its principal limitation due to aortic valve failure or homograft degeneration. We present our 25 years of experience in the pediatric population. From August 1994 until June 2018, 157 children below 18 years underwent the Ross operation. This retrospective review aims at assessing the long-term outcomes, as well as the risk factors for re-operation after Ross procedure. Median age was 10.9 years, of which seven patients were infants, 79 children, and 71 adolescents. The median follow-up time was 14 years. Hospital mortality was 0.6%. Freedom from autograft re-operation for children was 96.7% and 94.1% at 10 and 20 years, respectively; whereas for adolescents, it was 92.6% and 74.9% at 10 and 20 years. For children, freedom from homograft re-operation was 92.5%, 83.5%, and 56.2% at 10, 15, and 20 years; while for adolescents, it was 96.8%, 91.8%, and 86.7% at 10, 15, and 20 years. Homograft size (p = 0.008) and childhood (p = 0.05) were risk factors for homograft re-operation. Pulmonary valve diameter > 24 mm (p = 0.044) and adolescence (p = 0.032) were risk factors for autograft re-operation. Our experience demonstrated excellent early and late survival. While children have preferential outcomes concerning autograft re-operation, those who received a smaller homograft had a higher right-sided re-intervention incidence than adolescents. Pulmonary diameter > 24 mm at surgery was an indicator of future autograft failure.
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Affiliation(s)
- Alessandro Varrica
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy.
| | - Alessandro Giamberti
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Mauro Lo Rito
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Matteo Reali
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Mahmood Hafdhullah
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Angela Satriano
- Anesthesia and Intensive Care Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Antonio Saracino
- Pediatric and Adult Congenital Heart Centre, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Angelo Micheletti
- Pediatric and Adult Congenital Heart Centre, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alessandro Frigiola
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
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Said SM. The Ross-Konno procedure for congenital aortic stenosis. Ann Cardiothorac Surg 2021; 10:527-537. [PMID: 34422569 DOI: 10.21037/acs-2021-rp-31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/19/2021] [Indexed: 11/06/2022]
Abstract
Left ventricular outflow tract (LVOT) obstruction can result from supravalvular, valvular and/or subvalvular etiologies. Congenital aortic valvular stenosis is frequently associated with aortic annular hypoplasia. Aortoventriculoplasty with pulmonary autograft, "The Ross-Konno" operation, provides more or less a radical solution to multilevel LVOT obstruction by enlarging the aortic annulus and the subvalvular area, thus relieving both valvular and subvalvular obstructions. In addition to this, the procedure carries the major advantage of having a competent autograft in the LVOT. An autograft that has the potential for growth and provides excellent quality of life without the need for anticoagulation. The procedure is most commonly performed as a complete root implantation, harvesting the coronary arteries as buttons, and harvesting the autograft with a muscle skirt to allow a single unit reconstruction of the LVOT. The procedure has been modified over time to minimize the risk of conduction tissue injury and the development of complete heart block by modifying the interventricular septal incision. The Ross-Konno procedure has changed the approach to patients with complex multilevel LVOT obstruction. However, while it can be performed early in life, one should be aware that this procedure is technically demanding and can be associated with a higher surgical risk. Nevertheless, it is considered "the ultimate solution" for those with complex multilevel LVOT obstruction.
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Affiliation(s)
- Sameh M Said
- Division of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
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Moroi MK, Bacha EA, Kalfa DM. The Ross procedure in children: a systematic review. Ann Cardiothorac Surg 2021; 10:420-432. [PMID: 34422554 DOI: 10.21037/acs-2020-rp-23] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/10/2021] [Indexed: 12/20/2022]
Abstract
Background The Ross procedure involves autograft transplantation of the native pulmonary valve into the aortic position and reconstruction of the right ventricular outflow tract (RVOT) with a homograft. The operation offers the advantages of a native valve with excellent hemodynamic performance, the avoidance of anticoagulation, and growth potential. Conversely, the operation is technically demanding and imposes the risk of turning single-valve disease into double-valve disease. This systematic review reports outcomes of pediatric patients undergoing the Ross procedure. Methods An electronic search identified studies reporting outcomes on pediatric patients (mean age <18 years, max age <21 years) undergoing the Ross procedure. Long-term outcomes, including early mortality, late mortality, sudden unexpected unexplained death, reoperation due to failure of the pulmonary autograft or RVOT reconstruction, thromboembolic events, bleeding events, and endocarditis-related complications, were evaluated. Results Upon review of 2,035 publications, 30 studies and 3,156 pediatric patients were included. Patients had a median age of 9.5 years and median follow-up period of 5.7 years. Early mortality rates varied from 0.0 to 17.0% and were increased in the neonatal population. Late mortality rates were much lower (0.04-1.83%/year). Reoperation due to pulmonary autograft failure occurred at rates of 0.37-2.81%/year and reoperation due to RVOT reconstruction failure was required at rates of 0.34-4.76%/year. Thromboembolic, bleeding, and endocarditis events were reported to occur at rates of 0.00-0.58, 0.00-0.39, and 0.00-1.68%/year, respectively. Conclusions The Ross operation offers a durable aortic valve replacement (AVR) option in the pediatric population that offers favorable survival, excellent hemodynamics, growth potential, decreased risk of complications, and avoidance of anticoagulation. Larger multi-institutional registries focusing on pediatric patients are necessary to provide more robust evidence to further support use of the Ross procedure in this population.
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Affiliation(s)
- Morgan K Moroi
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Emile A Bacha
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - David M Kalfa
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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Fuller SM, Borisuk MJ, Sleeper LA, Bacha E, Burchill L, Guleserian K, Ilbawi M, Razzouk A, Shinkawa T, Lu M, Baird CW. Mortality and Reoperation Risk After Bioprosthetic Aortic Valve Replacement in Young Adults With Congenital Heart Disease. Semin Thorac Cardiovasc Surg 2021; 33:1081-1092. [PMID: 34174404 DOI: 10.1053/j.semtcvs.2021.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 11/11/2022]
Abstract
Bioprosthetic aortic valve replacement (bAVR) in patients with congenital heart disease is challenging due to age, size and complexity. Our objective was to assess survival and identify predictors of re-operation. Data were retrospectively collected for 314 patients undergoing bAVR at 8 centers from 2000-2014. Kaplan-Meier estimation of time to re-operation and Cox regression were utilized. Average age was 45.2 years (IQR 17.8-71.1) and 30% were <21. Indications were stenosis (48%), regurgitation (28%) and mixed (18%). Twenty-eight (9%) underwent prior AVR. Median valve size was 23mm (IQR 21, 25). Implanted valves included CE (Carpentier-Edwards) Perimount (47%), CE Magna/Magna Ease (29%), Sorin Mitroflow (9%), St Jude (2%) and other (13%). Median follow-up was 2.9 (IQR 1.2, 5.7) years. Overall, 11% required re-operation, 35% of whom had a Mitroflow and 65% were <21 years old. Time to re-operation varied among valve type (p=0.020). Crude 3-year rate was 20% in patients ≤21. Smaller valve size indexed to BSA was associated with re-operation (21.7 vs. 23.5 mm/m2). Predictors of reintervention by multivariable analysis were younger age (29% increase in hazard per 5-year decrease, p<0.001), Mitroflow (HR=4 to 8 versus other valves), and smaller valve size (20% increase in hazard per 1 mm decrease, p=0.002). The overall 1, 3 and 5-year survival rates were 94%, 90% and 85% without differences by valve (p=0.19). A concerning reduction in 5-year survival after bAVR is shown. Re-operation is common and varies by age and valve type. Further research is needed to guide valve choice and improve survival.
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Affiliation(s)
- Stephanie M Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania..
| | - Michele J Borisuk
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Emile Bacha
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian/Morgan Stanley Children's Hospital-Columbia/Komansky Weill-Cornell, New York, New York
| | - Luke Burchill
- Department of Medicine, University of Melbourne Royal Melbourne Hospital, Melbourne, New Zealand
| | - Kristine Guleserian
- Division of Cardiothoracic Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Michel Ilbawi
- Division of Pediatric Cardiac Surgery, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Anees Razzouk
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, California
| | - Takeshi Shinkawa
- Department of Cardiac Surgery, Tokyo Women's Medical University, Tokyo, JAPAN
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Ross Operation in Children: 23-Year Experience From a Single Institution. Ann Thorac Surg 2020; 109:1251-1259. [DOI: 10.1016/j.athoracsur.2019.10.070] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/15/2019] [Accepted: 10/28/2019] [Indexed: 11/19/2022]
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