Pulmonary autograft for aortic valve replacement in rheumatic disease: a caveat

The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement

The Ross procedure is gaining recognition as a significant option for aortic valve replacement (AVR), and is particularly beneficial in specific patient groups. Although categorized as a class IIb recommendation in the 2020 American College of Cardiology (ACC)/American Heart Association (AHA), and the European Society of Cardiology (ESC) management guidelines on valvular heart disease, recent studies bolster its credibility. Research, including a propensity-matched study, underlines the Ross procedure's association with enhanced long-term survival and reduced adverse valve-related events compared to other AVR types. This positions the Ross procedure as a primary option for AVR in young and middle-aged adults within specialized centers, and potentially the only choice for children and infants requiring AVR. This review meticulously examines the Ross procedure, covering historical perspectives, surgical techniques, imaging, and outcomes, including hemodynamic performance and quality of life, especially focusing on pediatric and young adult patients. It explores contemporary techniques and innovations like minimally invasive approaches and tissue engineering, underscoring ongoing research and future directions. A summarization of comparative studies and meta-analyses reiterates the Ross procedure's superior long-term outcomes, valve durability, and preservation of the left ventricular function, accentuating the crucial role of patient selection and risk stratification, and pinpointing areas for future research.

Rethinking the ross procedure in adults

BACKGROUND

Although questionable durability has tempered enthusiasm for the Ross procedure in the last decade, the perioperative risks of the Ross procedure relative to conventional aortic valve replacement are not well described. The goal of this study is to describe both the perioperative outcomes and utilization trends of the Ross procedure in adults in The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

METHODS

The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to review all Ross procedures performed between 1994 and 2010. The utilization of the procedure in the database was assessed. Then the preoperative comorbidities, patient demographics, and risk factors were reviewed, as were intraoperative and perioperative outcomes.

RESULTS

Of 648,541 aortic valve replacements during the study period, 3,054 (0.47%) were identified as Ross procedures. Utilization of the procedures as a percent of total aortic valve replacements peaked in 1998 at 1.2%, followed by a steady decline to 0.09% by 2010. More than a quarter of all Ross operations were performed at six sites. Using propensity-matching analyses, Ross patients experienced significantly more perioperative complications including reexploration (9.4% versus 5.8%; p < 0.01), renal failure (2.6% versus 0.8%; p < 0.001), and operative mortality (2.7% versus 0.9%; p = 0.001).

CONCLUSIONS

These data suggest that the Ross procedure is associated with greater perioperative morbidity and mortality risks compared with conventional aortic valve replacement. Recognition of these risks along with durability concerns have resulted in a dramatic decline in the number of Ross procedures performed in North America in the last decade.

The challenges of cardiac surgery for African children

Abstract

In Africa the specific pattern of cardiovascular diseases and lack of adequate measures for disease prevention and control result in the frequent need for open-heart surgery for the management of complications of cardiomyopathies in children. Several strategies and innovative ways of providing cardiovascular surgical care in African countries have been used, from agreements to send patients overseas, to programmes for the creation of local services to provide comprehensive care locally.

This article attempts to outline the challenges faced by underdeveloped countries in Africa wanting to embark on programmes of cardiac surgery and the need for several sectors of society to play a role in the process. It discusses issues related to the establishment of centres performing cardiac surgery in Africa, describes the treatment of congenital heart disease, and reviews the aspects of management of conditions highly prevalent in or mostly confined to this continent, such as rheumatic heart valve disease and endomyocardial fibrosis.

Update on the mitral pulmonary autograft

Between July 1997 and August 2004, 92 patients with irreparable mitral valves underwent replacement with a pulmonary autograft. This report brings the follow-up data of these patients up to date. Eighty-eight patients had a successful Ross II operation; 4 were lost to follow-up. The mean follow-up period was 94 months. Transesophageal echocardiography revealed a successful outcome in all 88 patients immediately after the operation. Operative mortality was 4.6%, and late mortality definitely related to the operation was 12.5%. At a mean follow-up of 94 months, freedom from structural valve deterioration (significant mitral stenosis and/or regurgitation) was 93.4%, freedom from reoperation was 92.0%, and freedom from all causes of death was 82.9%. Two autografts were explanted because of endocarditis. Two patients developed significant pulmonary stenosis, one of whom underwent operative repair. These data compare favorably with those of mitral valve replacement using modern bioprostheses. This procedure remains an option for the relatively young patient when life-long anticoagulation is contraindicated or impractical. It is also an option to consider in infants with complex irreparable mitral valve disease.

In young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure?

A best evidence topic in cardiac surgery was written, according to a structured protocol. The question addressed was: in young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure? The pulmonary autograft with its inherent advantages of viable autologous transplant, central laminar flow, freedom from prosthetic valve complications, side effects of anticoagulation, and growth potential is considered a well-accepted option for aortic valve replacement in young patients. However, the use of a pulmonary autograft in young patients with rheumatic aortic valve disease is controversial. We analyse existing evidence to determine the suitability of the pulmonary autograft as a substitute for the diseased aortic valve in patients with rheumatic disease. Altogether 901 papers were found using the reported search terms, from which eight represented the best evidence to answer the clinical question. In addition, a meta-analysis also superficially addressed this issue. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All eight publications were from two institutions with one reporting outcomes for a Ross operation vs. mechanical valve implantation and two compared results of the Ross operation in rheumatic vs. non-rheumatic aortic valve disease. We conclude that the current available evidence suggests that pulmonary autograft is susceptible to rheumatic involvement. Use of pulmonary autograft in young patients (<30 years) with rheumatic aortic regurgitation and concomitant mitral regurgitation requires a cautious approach as there is an impaired autograft durability in this subgroup of patients.

The malignant course of acute rheumatic Fever in the modern era: implications for early surgical intervention in cases of bivalvular insufficiency with impaired ventricular function

In recent years, the incidence of acute rheumatic fever (ARF) has drastically decreased in the United States while remaining common in developing nations. However, immigration to the United States from developing nations has resulted in the continued prevalence of ARF. Patients with ARF face the potential development of significant valvular insufficiency and rheumatic carditis, which are associated with significant morbidity and mortality. Potentially adverse outcomes may be avoided with advanced interventions such as aortic and/or mitral valve replacement or repair, the use of inotropic agents, and ventricular assist devices for mechanical circulatory support. This report describes a series of three ARF carditis cases. This series serves not only to emphasize proper ARF prevention, but also to demonstrate the need for timely surgical intervention once medical therapy has failed.

What is the proper place of the ross procedure in our modern armamentarium?

Despite nearly four decades of experience, the role of pulmonary valve autotransplantation (Ross procedure) in the treatment of aortic valve disease in adults and children continues to evolve and remains controversial. As the picture of late results has unfolded, alternating waves of enthusiasm and caution have characterized its use and have led to ongoing refinements in indications and operative technique. At present, it is seen as indispensable in the treatment of aortic valve disease in infants and small children (for whom no satisfactory replacement alternative exists and for whom growth is essential), attractive for adolescents and young adults who wish to avoid anticoagulants because of childbirth and lifestyle considerations, a reasonable option for selected adults who desire biologic solutions with potentially better durability than conventional bioprostheses, and contraindicated for the elderly and those with connective tissue disorders. Young patients with bicuspid aortic valve are the most common potential recipients, but also the most controversial, because of the risk of autograft dilatation. Optimal matching of prosthesis to patient is a clinical challenge for all caretakers involved in the treatment of valvular heart disease; this review provides guidelines to identify those patients who will benefit most from the Ross procedure, and those for whom it is inadvisable.

Current Status of Surgery for Rheumatic Carditis in Children

BACKGROUND

The incidence of rheumatic heart disease (RHD) has increased recently in the western United States. We reviewed our 18-year surgical experience with RHD in children to examine current surgical techniques and results.

METHODS

From 1985 until 2003, 596 children (<21 years) with rheumatic fever were seen at Primary Children's Medical Center. Rheumatic carditis was diagnosed in 366 patients (61.4%). Twenty-six with carditis (26/366, 7.1%) required operation for rheumatic valve disease including 8 for mitral regurgitation, 7 for mitral and aortic regurgitation, 4 for aortic regurgitation, 4 for mitral regurgitation and stenosis, 2 for combined mitral stenosis and regurgitation with aortic insufficiency, and 1 for mitral and tricuspid regurgitation.

RESULTS

Mean age at operation was 13.5 +/- 4 years. Three patients required operation during the acute phase of rheumatic fever (< 6 weeks), 2 during the subacute phase (< 6 months), and 21 during the chronic phase after the episode of rheumatic fever (6.7 +/- 3 years). Mitral valve repair was possible in 19 of 22 patients who required mitral operation. Aortic valve repair was possible in 4 patients whereas replacement was necessary in 9, including 2 Ross procedures. No operative deaths were recorded and 2 late deaths occurred at 4.6 and 10 years. Actuarial survival was 94% at 5 years and 78% at 10 years. Six patients required reoperation; actuarial freedom from reoperation was 78% at 5 years, 65% at 10 years, and 49% at 15 years. All survivors are in New York Heart Association class I or II.

CONCLUSIONS

Children with RHD in the United States uncommonly require valve operation. Mitral repair with a technique that allows annular growth is possible in most children with good long-term functional results. Long-term surveillance of children with RHD is necessary because of the possible need for late valve operation.

The Ross Procedure

BACKGROUND

The search for the ideal substitute for the aortic valve led Donald Ross to develop the pulmonary autograft concept in 1967. A historical, technical, and scientific review of this surgical option is presented together with our clinical experience.

MATERIALS AND METHODS

The literature is reviewed to identify the advantages and pitfalls of the Ross procedure over the last decades. We also present our clinical experience with 92 patients operated between 1997 and May 2003.

RESULTS

Of the total, 70.65% (n = 65) were males, mean age was 29.32 +/- 11.9 years, with 20 patients under 16 and 6 patients under 10 years. Twenty-five patients (27.17%) had 31 previous interventions. There were 41 associated procedures in 34 patients. Perioperative mortality was 2.17% (two patients). Eight patients required reexploration for bleeding, one required an aortocoronary bypass, and one a permanent pacemaker. Follow-up was 97% with 2.71 patients/year (average 32.55 +/- 19.01 months). Two patients required autograft replacement, one suffered a 44-mm dilatation of the autograft, and one 13-year-old girl developed autograft endocarditis. Six patients suffered severe homograft stenosis (>50 mmHg), two were treated percutaneously, and one required replacement. Combined freedom from reintervention is 93.56 +/- 2.81% at 5 years.

CONCLUSIONS

The Ross procedure is a mature concept with thousands of patients operated worldwide and a cumulative experience of over 30 years. Although we believe that it is the procedure of choice in the pediatric population, women in child-bearing age, and substantial subgroups of adult patients, efforts must continue to minimize the incidence of auto- and homograft failure in the long term.

The Ross procedure is the procedure of choice for congenital aortic valve disease

OBJECTIVES

The Ross procedure has emerged as an attractive option for aortic valve replacement in children and young adults. Our objective was to review our experience with the Ross procedure in young patients with congenital aortic valve disease. We also sought for evidence of growth in the autograft.

METHODS

From January 1990 to July 2000, 260 patients underwent the Ross procedure for various aortic valve diseases. There were 136 patients less than 18 years of age. Fifty-three (38%) of these patients had congenital aortic valve disease. Ages ranged from 3 months to 18 years (mean, 8 plus minus 5 years; median, 9 years). Ten patients were less than 2 years of age. Pure aortic stenosis was present in 18 patients, mixed stenosis and regurgitation in 32, and pure aortic regurgitation in 3. The aortic valve was bicuspid in 29 patients. Twenty-nine patients had previous procedures, mostly balloon dilation of the aortic valve (n = 8) or surgical aortic valvotomy (n = 12).

RESULTS

In all patients immediate results demonstrated a normally functioning neoaortic valve with not more than trivial aortic valve regurgitation. In the patients with stenosis, all levels of obstruction were relieved, and the gradient across the left ventricular outflow tract was completely abolished. Hospital mortality was 3 (5.6%) of 53 (overall Ross mortality was 34 of 260 [1.5%]). The patients were followed up for a mean of 4 years and up to 10 years. One patient died late of a noncardiac cause. Actuarial survival at 10 years was 94% plus minus 2%, and freedom from all events was 93% plus minus 5%. Only 1 patient needed autograft replacement for endocarditis. Intervention related to right ventricle-pulmonary artery conduit was required in 3 patients: balloon dilatation in 2, and reoperation in 1. At last follow-up, all patients but one were classified as being in New York Heart Association functional class I or II with normal or near-normal autograft valve function. Serial measurement of the left ventricular outflow tract and aortic root showed that as patients grew, the size of the outflow tract increased. When indexed to body surface area, this increase correlated with the patients' expected somatic growth.

CONCLUSIONS

The Ross procedure for congenital aortic valve disease in children and young adults offers excellent hemodynamics, with the added advantage of real potential for growth. It should be considered the treatment of choice in this age group.

Pulmonary autograft: should it be used in young patients with rheumatic disease?

BACKGROUND

Although pulmonary autograft is being increasingly used to replace the diseased aortic valve with excellent long-term results, its use in the population with rheumatic disease still needs careful evaluation.

PATIENTS AND METHODS

From October 1993 through March 1998, 102 patients underwent aortic valve replacement with a pulmonary autograft (Ross procedure). The mean age was 27.9 +/- 4.2 years (range, 0.8-56 years). The cause was rheumatic disease in 75 patients (73%), bicuspid aortic valve in 26 patients (26%), and myxomatous aortoarteritis in 1 patient (1%). The root replacement technique was used in all. In addition, 31 patients had 33 associated procedures: mitral valve repair (n = 15 patients), open mitral commissurotomy (n = 15 patients), tricuspid repair (n = 2 patients), and homograft mitral valve replacement (n = 1 patient).

RESULTS

Operative mortality was 6.9% (7 patients). Late mortality was 7.8% (8 patients). Follow-up ranged from 1 to 60 months (mean, 25.3 +/- 15.4 months) and was 98% complete. Two patients required reoperation for failed mitral valve repair, and 2 other patients underwent reoperation for failure of both the autograft and mitral valve repair. Echocardiographic assessment showed moderate to severe aortic regurgitation in 13 patients, along with thickening of the autograft. All of these patients had rheumatic disease and were young (<30 years). Ten of these patients had undergone associated mitral valve procedure. Morphologic and histopathologic examination of explanted autografts showed features compatible with rheumatic valvulitis.

CONCLUSION

Pulmonary autograft is susceptible to rheumatic involvement. Young age (<30 years) and associated mitral valve disease are significant risk factors for autograft failure in patients with rheumatic disease. Use of pulmonary autograft in this subgroup of patients requires a cautious approach.

Semilunar valve switch procedure: autotransplantation of the native aortic valve to the pulmonary position in the Ross procedure

BACKGROUND

The Ross procedure has gained wide acceptance in young patients with aortic valve disease. The durability of the pulmonary autograft in the aortic position has been proved, with up to 24 years of follow-up. The homograft pulmonary valve, however, has limited longevity. To circumvent this problem we harvested, repaired, and reimplanted the native aortic valve with intact commissures in the pulmonary position in 13 patients undergoing the Ross procedure for aortic insufficiency.

METHODS

The cause of aortic insufficiency was rheumatic in 6 patients, congenital in 4, post-aortic valvotomy in 2, and bacterial endocarditis in 1. Patient age ranged from 5 to 45 years (mean, 17+/-9 years). Root replacement technique with coronary artery reimplantation was used. In the first 4 patients, the native aortic valve was sutured into the right ventricular outflow tract, and a polytetrafluorethylene patch was used to reconstruct the main pulmonary artery. In the last 9 patients, the aortic valve and polytetrafluorethylene patch were made into a conduit by another surgeon while the left-sided reconstruction was performed.

RESULTS

All patients had marked reduction of left ventricular dilation and good function of the reimplanted native aortic valve, with up to 50 months of follow-up (mean, 29.9+/-14.2 months; range, 12 to 50 months). Two patients died 15 and 26 days, respectively, of a false aneurysm rupture at the distal aortic anastomosis. In the remaining 11 patients, 9 (82%) had mild or absent, and 2 (18%) had mild to moderate, neoaortic valve regurgitation. Similarly, 9 patients (82%) had mild or absent, and 2 (18%) had mild to moderate, neopulmonary valve regurgitation. Mild neopulmonary valve stenosis was present in 6 patients (54%) (mean gradient, 29+/-4 mm Hg; range, 25 to 35 mm Hg). All surviving patients are in functional New York Heart Association functional class I.

CONCLUSIONS

We conclude that use of the native aortic valve with the Ross procedure makes the procedure attractive and potentially curative. The diseased aortic valve works well in the pulmonary position because of lower pressure and resistance. The valve leaflets should remain viable and grow in both the pulmonary and aortic positions because they derive nutrition directly from the blood.

The role of intraoperative echocardiography in valve surgery

The widespread use and popularity of intraoperative echocardiography (IOE) has resulted from advances in cardiac surgery, reparative procedures for valvular heart disease and, most specifically, mitral valve repair. IOE has grown exponentially and is becoming an integral part of the planning and evaluation of many types of surgical procedures such that it is now considered standard of care especially for the perioperative management of patients undergoing mitral and aortic valve repair. This article discusses the application of intraoperative echocardiography and focus specifically on valvular heart disease as this represents the most widely accepted indication for the procedure in current clinical practice.

Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series

BACKGROUND

Pulmonary autograft replacement of the diseased aortic valve has not been widely practiced due to concerns regarding late autograft competence and the consequences of creating pulmonary valve disease. To investigate this, the fate of the pioneering series of patients has been determined.

METHODS AND RESULTS

The 131 hospital survivors of the pulmonary autograft operation at the National Heart Hospital from 1967 to 1984 were identified and their outcomes determined to 1994. Age at operation was 11 to 52 years, and 109 patients were male. Autograft implantation was orthotopic subcoronary (107), free-standing root (20), or Dacron mounted (2). In 113 patients, homografts replaced the native pulmonary valve. Ten and 20 years after operation, survival was 85% and 61%, freedom from autograft replacement was 88% and 75%, and freedom from replacement of pulmonary position homografts was 89% and 80%, respectively. Causes of deaths (53) included chronic heart failure (13), complications of reoperation (12), and endocarditis (7). Autograft regurgitation, the most common indication for reoperation, appeared primarily technical in nature, usually due to cusp prolapse. Degeneration was found in only 3 of 30 explanted autografts, and the young patients showed no increase in late valve failure. Homografts outperformed other valve replacements in the pulmonary position, but patients with orthotopic subcoronary and root autografts survived similarly.

CONCLUSIONS

The pulmonary autograft offers low rates of degeneration, endocarditis, and thromboembolism for a period lasting >20 years, particularly in the young, with reoperation mainly required for malpositioning of the autograft cusps. The capacity of the autograft to maintain viability with minimal degeneration is not matched by any other biological valve replacement.