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El-Hamamsy I, Vricella LA. Late Pulmonary Autograft Dilation: Can We Make a Good Operation Great? The Tailored Approach. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2024; 27:42-46. [PMID: 38522871 DOI: 10.1053/j.pcsu.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 03/26/2024]
Abstract
While it is the main viable option in the growing child and young adult, the Ross procedure has expanded its applicability to older patients, for whom long-term results are equivalent, if not superior, to prosthetic aortic valve replacement. Strategies aiming at mitigating long-term autograft failure from root enlargement and valve regurgitation have led some to advocate for root reinforcement with prosthetic graft material. On the contrary, we will discuss herein the rationale for a tailored approach to the Ross procedure; this strategy is aimed at maintaining the natural physiology and interplay between the various autograft components. Several technical maneuvers, including careful matching of aortic and autograft annuli and sino-tubular junction as well as external support by autologous aortic tissue maintain these physiologic relationships and the viability of the autograft, and could translate in a lower need for late reintervention because of dilation and/or valve regurgitation.
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Affiliation(s)
- Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Luca A Vricella
- Division of Cardiac Surgery, University of Chicago and Advocate Children's Hospital Chicago, Illinois..
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Notenboom ML, Melina G, Veen KM, De Robertis F, Coppola G, De Siena P, Navarra EM, Gaer J, Ibrahim MEK, El-Hamamsy I, Takkenberg JJM, Yacoub MH. Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Cardiol 2024; 9:6-14. [PMID: 37938855 PMCID: PMC10633393 DOI: 10.1001/jamacardio.2023.4090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/24/2023] [Indexed: 11/10/2023]
Abstract
Importance The Ross procedure as treatment for adults with aortic valve disease (AVD) has been the subject of renewed interest. Objective To evaluate the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with AVD. Design, Setting, and Participants This post hoc analysis of a randomized clinical trial included adult patients (age <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. Exposure Ross procedure. Main Outcomes and Measures The primary end point was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin- and sex-matched general population. Secondary end points were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. Results This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%). Conclusions and Relevance This study found that the Ross procedure provided excellent survival into the third decade postoperatively that was comparable to that in the general population. Long-term freedom from reintervention demonstrated that the Ross procedure may be a durable substitute into late adulthood, showing a delayed but progressive functional decline. Trial Registration isrctn.org Identifier: ISRCTN03530985.
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Affiliation(s)
- Maximiliaan L. Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Giovanni Melina
- Department of Cardiac Surgery, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Kevin M. Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fabio De Robertis
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Giuditta Coppola
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Paolo De Siena
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Emiliano M. Navarra
- Department of Cardiac Surgery, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Jullien Gaer
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | | | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Johanna J. M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Surgery Department, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
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Yacoub MH, Notenboom ML, Melina G, Takkenberg JJM. Surgical Heritage: You Had to Be There, Ross: The Comeback Kid. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2023; 27:37-41. [PMID: 38522870 DOI: 10.1053/j.pcsu.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 03/26/2024]
Abstract
Half a century after the first pulmonary autograft operation (Ross operation), performed in 1967 by Donald Ross in central London, there is a very strong conviction that the Ross operation is the best available valve substitute today, not only for children, but also for younger and older adults. The Ross operation has stimulated a lot of science to do with tissue-engineering and biology of heart valves, which is a promising avenue for the future. For one of us (M.Y.), it has certainly been a privilege to be associated with the comeback of the Ross operation.
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Affiliation(s)
- Magdi H Yacoub
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Heart Science Centre, Magdi Yacoub Institute, Harefield, United Kingdom.
| | | | - Giovanni Melina
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Gofus J, Fila P, Vobornik M, Ondrasek J, Nemec P, Sterba J, Cermakova E, Tuna M, Vojacek J. Unicuspid Aortic Valve in Patients Undergoing the Ross Procedure. Ann Thorac Surg 2023; 115:626-631. [PMID: 35430219 DOI: 10.1016/j.athoracsur.2022.03.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/28/2022] [Accepted: 03/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The prevalence and outcomes of the unicuspid aortic valve (UAV) in patients undergoing the Ross procedure have been strongly underreported in the current literature. We sought to evaluate this in comparison with bicuspid (BAV) and tricuspid valve (TAV) in our Ross cohort. METHODS This was a retrospective observational study of patients undergoing the Ross procedure at 2 dedicated centers between 2009 and 2020. Primary end points were the risks of midterm autograft reoperation and the onset of at least moderate aortic regurgitation during follow-up. The secondary end point was to compare the perioperative outcomes between the groups. RESULTS Included in the analysis were 286 patients, of those 39% with UAV, 52% with BAV, and 9% with TAV. UAV patients were operated on at the youngest age (P < .001) and more often for a combined hemodynamic aortic valve pathology (P = .02). They had the largest aortic root dimensions: annulus (P = .01), Valsalva sinuses (P = .11), sinotubular junction (P = .001), and ascending aorta (P < .0001). The risks of reoperation (P = .86) and the onset of aortic regurgitation (P = .75) were comparable among the groups over the follow-up of 4.1 years. There was no difference in perioperative outcomes. CONCLUSIONS UAV is a separate unit characterized by a distinct hemodynamic pathology and generated aortopathy. It is not associated with a higher risk of reoperation or new onset of aortic regurgitation after the Ross procedure in the midterm postoperatively. At the current state, UAV remains acceptable for the Ross procedure.
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Affiliation(s)
- Jan Gofus
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petr Fila
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Department of Cardiovascular Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Martin Vobornik
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jiri Ondrasek
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Nemec
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Department of Cardiovascular Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Sterba
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Department of Cardiovascular Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Eva Cermakova
- Department of Medical Biophysics, Charles University Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Martin Tuna
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
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The Ross operation after removal of a transcatheter aortic valve replacement in pediatric patients. JTCVS Tech 2022; 17:129-132. [PMID: 36820350 PMCID: PMC9938385 DOI: 10.1016/j.xjtc.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/26/2022] [Accepted: 10/13/2022] [Indexed: 12/12/2022] Open
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Gofus J, Karalko M, Fila P, Ondrášek J, Schäfers HJ, Kolesár A, Lansac E, El-Hamamsy I, de Kerchove L, Dinges C, Hlubocký J, Němec P, Tuna M, Vojáček J. Comparison of bicuspidization and Ross procedure in the treatment of unicuspid aortic valve disease in adults – Insight from the AVIATOR registry. Front Cardiovasc Med 2022; 9:900426. [PMID: 36158795 PMCID: PMC9493194 DOI: 10.3389/fcvm.2022.900426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background Unicuspid aortic valve (UAV) is the second most common underlying cause of aortic valve dysfunction in young adults after the bicuspid valve. The valve may be replaced (for example by pulmonary autograft) or repaired using the bicuspidization technique. The aim of our study was to compare short- and mid-term outcomes of Ross procedure with bicuspidization in patients with severe UAV dysfunction. Methods This was a multi-center retrospective observational cohort study comparing data from two dedicated Ross centers in the Czech Republic with bicuspidization outcomes provided by AVIATOR registry. As for the Ross group, only the patients with UAV were included. Primary endpoint was mid-term freedom from reintervention. Secondary endpoints were mid-term freedom from major adverse events, endocarditis and pacemaker implantation. Results Throughout the study period, 114 patients underwent the Ross procedure (years 2009-2020) and 126 patients underwent bicuspidization (years 2006-2019). The bicuspidization group was significantly younger and presented with a higher degree of dyspnea, a lower degree of aortic valve stenosis and more often with pure regurgitation. The primary endpoint occurred more frequently in the bicuspidization group than in the Ross group – 77.9 vs. 97.9 % at 5 years and 68.4 vs. 75.2 % at 10 years (p < 0.001). There was no difference in secondary endpoints. Conclusion Ross procedure might offer a significantly lower mid-term risk of reintervention than bicuspidization in patients with UAV. Both procedures have comparable survival and risk of other short- and mid-term complications postoperatively.
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Affiliation(s)
- Ján Gofus
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove and Charles University, Hradec Kralove, Czechia
| | - Mikita Karalko
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove and Charles University, Hradec Kralove, Czechia
| | - Petr Fila
- Department of Cardiac Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czechia
- *Correspondence: Petr Fila
| | - Jiří Ondrášek
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czechia
| | | | - Adrian Kolesár
- East Slovakian Institute for Cardiac and Vascular Diseases, Košice, Slovakia
| | | | - Ismail El-Hamamsy
- Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | | | - Jaroslav Hlubocký
- Department of Cardiovascular Surgery, General University Hospital, Prague, Czechia
| | - Petr Němec
- Department of Cardiac Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czechia
| | - Martin Tuna
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove and Charles University, Hradec Kralove, Czechia
| | - Jan Vojáček
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove and Charles University, Hradec Kralove, Czechia
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Pulmonary valve replacement: a new paradigm with tissue engineering. Curr Probl Cardiol 2022:101212. [PMID: 35460681 DOI: 10.1016/j.cpcardiol.2022.101212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 11/21/2022]
Abstract
Prevalence of congenital heart diseases worldwide is around 9 per 1000 newborns, 20% of which affect the pulmonary valve or right ventricular outflow tract. As survival after surgical repair of these defects has improved over time, there is the need to address the long-term issues of older children and young adults with "repaired" congenital heart diseases. In recent decades, the most used types of valves are the mechanical and bioprosthetic valves. Despite improving patients' quality of life, these effects are suboptimal due to their limitations, such as the inability to grow and adapt to hemodynamic changes. These issues have led to the search for living valve solutions through tissue engineering to respond to these challenges. This review aims to review the performance of traditional pulmonary valves and understand how tissue engineering-based valves can improve the management of these patients.
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Tanaka D, Mazine A, Ouzounian M, El-Hamamsy I. Supporting the Ross procedure: preserving root physiology while mitigating autograft dilatation. Curr Opin Cardiol 2022; 37:180-190. [PMID: 35081548 DOI: 10.1097/hco.0000000000000949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to describe the optimized approach to nonrepairable aortic valve disease in young adults with a Ross procedure, while preserving the dynamic physiology of the aortic root. RECENT FINDINGS As the techniques for supporting pulmonary autografts continue to be refined, and the applicability of the Ross procedure continues to expand, an assessment of the various techniques based on aortic root physiology is warranted. Semi-resorbable scaffolds show promise in ovine models for improving the Ross procedure. Recent long-term outcomes for the Dacron inclusion technique in comparison to more physiologic methods of support emphasize the importance of balancing the prevention of early dilatation with the preservation of root haemodynamics. As this review will synthesize, the dynamic physiology of the root may be preserved even in patients at a higher risk of autograft dilatation. SUMMARY The favourable long-term outcomes of the Ross procedure can be partly attributed to the ability of the autograft to restore dynamism to the neoaortic root. Patient-specific modifications that respect root physiology can tailor the Ross procedure to address each patient's risk factors for early dilatation and late failure. As such, the Ross procedure should be recognized as an increasingly favourable solution for a wide spectrum of nonpreservable aortic valve disease in young adults.
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Affiliation(s)
| | | | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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El-Hamamsy I, Toyoda N, Itagaki S, Stelzer P, Varghese R, Williams EE, Erogova N, Adams DH. Propensity-Matched Comparison of the Ross Procedure and Prosthetic Aortic Valve Replacement in Adults. J Am Coll Cardiol 2022; 79:805-815. [PMID: 35210036 DOI: 10.1016/j.jacc.2021.11.057] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND There has recently been renewed interest in the Ross procedure in adults. OBJECTIVES The goal of this study was to compare long-term outcomes after the Ross procedure vs biological and mechanical aortic valve replacement (AVR) in adults (aged 18-50 years) undergoing aortic valve surgery. METHODS Mandatory California and New York databases were queried between 1997 and 2014. Exclusion criteria included: ≥1 concomitant procedure, reoperations, infective endocarditis, intravenous drug use, hemodialysis, and out-of-state residency. Propensity matching (1:1:1) was used, resulting in 434 patients per group. The primary endpoint was all-cause mortality. Secondary endpoints were stroke, major bleeding, reoperation, and endocarditis. Median follow-up was 12.5 years (IQR: 9.3-15.7 years). RESULTS At 15 years, actuarial survival after the Ross procedure was 93.1% (95% CI: 89.1%-95.7%), similar to that of the age-, sex-, and race-matched U.S. general population. It was significantly lower after biological AVR (HR: 0.42; 95% CI: 0.23-0.075; P = 0.003) and mechanical AVR (HR: 0.45; 95% CI: 0.26-0.79; P = 0.006). At 15 years, the Ross procedure was associated with a lower cumulative risk of reintervention (P = 0.008) and endocarditis (P = 0.01) than biological AVR. In contrast, at 15 years, the Ross procedure was associated with a higher cumulative incidence of reoperation (P < 0.001) but lower risks of stroke (P = 0.03) and major bleeding (P = 0.016) than mechanical AVR. Thirty-day mortality after valve-related complications was lowest after a reintervention. CONCLUSIONS In young adults, the Ross procedure is associated with better long-term survival and freedom from valve-related complications compared with prosthetic AVR. This confirms the notion that a living valve substitute in the aortic position translates into improved clinically relevant outcomes.
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Affiliation(s)
- Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Nana Toyoda
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shinobu Itagaki
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paul Stelzer
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robin Varghese
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elbert E Williams
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Natalia Erogova
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Gofus J, Fila P, Drabkova S, Zacek P, Ondrasek J, Nemec P, Sterba J, Tuna M, Jarkovsky J, Vojacek J. Ross procedure provides survival benefit over mechanical valve in adults: a propensity-matched nationwide analysis. Eur J Cardiothorac Surg 2022; 61:1357-1365. [PMID: 35150238 DOI: 10.1093/ejcts/ezac013] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 11/15/2021] [Accepted: 01/05/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES The choice of optimal surgical treatment for young and middle-aged adults with aortic valve disease remains a challenge. Mechanical aortic valve replacement (mAVR) is generally preferred despite promising recent outcomes of the Ross procedure. Our goal was to compare the strategies at a nationwide level. METHODS This study was a retrospective analysis of prospectively recorded data from the National Registry of Cardiac Surgery of the Czech Republic. Using propensity score matching, we compared the outcomes of patients undergoing the Ross procedure in 2 dedicated centres with all mAVRs performed in country between 2009 and 2020. RESULTS Throughout the study period, 296 adults underwent the Ross procedure and 5120 had an mAVR. We found and compared 291 matched pairs. There were no in-hospital deaths, and the risk of perioperative complications was similar in both groups. Over the average follow-up period of 4.1 vs 6.1 years, the Ross group had a lower all-cause mortality (0.7 vs 6.5%; P = 0.015). This result remained significant even when accounting for cardiac- and valve-related deaths only (P = 0.048). Unlike the Ross group, the mAVR group had a significantly lower relative survival compared with the age- and sex-matched general population. There was no difference in the risk of reoperation (4.5 vs 5.5%; P = 0.66). CONCLUSIONS The Ross procedure offers a significant midterm survival benefit over mAVR. The procedures have a comparable risk of perioperative complications. Patients after mAVR have reduced survival. Thus, the Ross procedure should be the preferred treatment option for young and middle-aged adults with aortic valve disease in dedicated centres.
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Affiliation(s)
- Jan Gofus
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petr Fila
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Svetlana Drabkova
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jiri Ondrasek
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Nemec
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Jan Sterba
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Martin Tuna
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jiri Jarkovsky
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
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Van Hoof L, Verbrugghe P, Jones EAV, Humphrey JD, Janssens S, Famaey N, Rega F. Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts. Front Cardiovasc Med 2022; 9:829120. [PMID: 35224059 PMCID: PMC8865563 DOI: 10.3389/fcvm.2022.829120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
The Ross, or pulmonary autograft, procedure presents a fascinating mechanobiological scenario. Due to the common embryological origin of the aortic and pulmonary root, the conotruncus, several authors have hypothesized that a pulmonary autograft has the innate potential to remodel into an aortic phenotype once exposed to systemic conditions. Most of our understanding of pulmonary autograft mechanobiology stems from the remodeling observed in the arterial wall, rather than the valve, simply because there have been many opportunities to study the walls of dilated autografts explanted at reoperation. While previous histological studies provided important clues on autograft adaptation, a comprehensive understanding of its determinants and underlying mechanisms is needed so that the Ross procedure can become a widely accepted aortic valve substitute in select patients. It is clear that protecting the autograft during the early adaptation phase is crucial to avoid initiating a sequence of pathological remodeling. External support in the freestanding Ross procedure should aim to prevent dilatation while simultaneously promoting remodeling, rather than preventing dilatation at the cost of vascular atrophy. To define the optimal mechanical properties and geometry for external support, the ideal conditions for autograft remodeling and the timeline of mechanical adaptation must be determined. We aimed to rigorously review pulmonary autograft remodeling after the Ross procedure. Starting from the developmental, microstructural and biomechanical differences between the pulmonary artery and aorta, we review autograft mechanobiology in relation to distinct clinical failure mechanisms while aiming to identify unmet clinical needs, gaps in current knowledge and areas for further research. By correlating clinical and experimental observations of autograft remodeling with established principles in cardiovascular mechanobiology, we aim to present an up-to-date overview of all factors involved in extracellular matrix remodeling, their interactions and potential underlying molecular mechanisms.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Jay D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Nappi F, Iervolino A, Avtaar Singh SS. The effectiveness and safety of pulmonary autograft as living tissue in Ross procedure: a systematic review. Transl Pediatr 2022; 11:280-297. [PMID: 35282027 PMCID: PMC8905099 DOI: 10.21037/tp-21-351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Reports on effectiveness and safety after the implant of pulmonary autograft (PA) living tissue in Ross procedure, to treat both congenital and acquired disease of the aortic valve and left ventricular outflow tract (LVOT), show variable durability results. We undertake a quantitative systematic review of evidence on outcome after the Ross procedure with the aim to improve insight into outcome and potential determinants. METHODS A systematic search of reports published from October 1979 to January 2021 was conducted (PubMed, Ovid Medline, Ovid Embase and Cochrane library) reporting outcomes after the Ross procedure in patients with diseased aortic valve with or without LVOT. Inclusion criteria were observational studies reporting on mortality and/or morbidity after autograft aortic valve or root replacement, completeness of follow-up >90%, and study size n≥30. Forty articles meeting the inclusion criteria were allocated to two categories: pediatric patient series and young adult patient series. Results were tabulated for a clearer presentation. RESULTS A total of 342 studies were evaluated of which forty studies were included in the final analysis as per the eligibility criteria. A total of 8,468 patients were included (7,796 in pediatric cohort and young adult series and 672 in pediatric series). Late mortality rates were remarkably low alongside similar age-matched mortality with the general population in young adults. There were differences in implantation techniques as regard the variability in stress and the somatic growth that recorded conflicting outcomes regarding the miniroot vs the subcoronary approach. DISCUSSION The adaptability of lung autograft to allow for both stress variability and somatic growth make it an ideal conduit for Ross's operation. The use of the miniroot technique over subcoronary implantation for better adaptability to withstand varying degrees of stress is perhaps more applicable to different patient subgroups.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
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13
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Skillington P, Tripathy AK, Keefe MO, Larobina M. Right-sided reconstruction during the Ross procedure—A technical perspective for long-term durability. JTCVS Tech 2021; 10:403-407. [PMID: 34984396 PMCID: PMC8691921 DOI: 10.1016/j.xjtc.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
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14
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Mazine A, El-Hamamsy I. Tailoring the Ross procedure for patients with aortic regurgitation. JTCVS Tech 2021; 10:383-389. [PMID: 34977760 PMCID: PMC8690315 DOI: 10.1016/j.xjtc.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/03/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
- Address for reprints: Ismail El-Hamamsy, MD, PhD, Department of Cardiovascular Surgery, Mount Sinai Hospital, 1190, Fifth Ave, New York, NY 10029.
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15
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Ibrahim M, Fukuhara S. More Data "In Support" of the Ross. Ann Thorac Surg 2021; 114:509-510. [PMID: 34740584 DOI: 10.1016/j.athoracsur.2021.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Michael Ibrahim
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan, 1500 E. Medical Center Drive Ann Arbor, MI, 48109.
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16
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Van Hoof L, Claus P, Jones EAV, Meuris B, Famaey N, Verbrugghe P, Rega F. Back to the root: a large animal model of the Ross procedure. Ann Cardiothorac Surg 2021; 10:444-453. [PMID: 34422556 DOI: 10.21037/acs-2020-rp-21] [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: 09/25/2020] [Accepted: 03/29/2021] [Indexed: 12/16/2022]
Abstract
The excellent clinical outcomes of the Ross procedure and previous histological studies suggest that the pulmonary autograft has the potential to offer young patients a permanent solution to aortic valve disease. We aim to study the early mechanobiological adaptation of the autograft. To this end, we have reviewed relevant existing animal models, including the canine models which enabled Donald N Ross to perform the first Ross procedure in a patient in 1967. Two research groups recently evaluated the isolated effect of systemic pressures on pulmonary arterial tissue in an ovine model of a pulmonary artery interposition graft in the descending aorta. While this model is ideal to study the artery's biological response and the effect of external support, it does not recreate the complex environment of the aortic root. The freestanding Ross procedure has been performed in pigs and sheep before. These studies offered valuable insights into leaflet growth and histological remodeling, yet may be less relevant to adults undergoing the Ross procedure, as pronounced autograft dilatation was achieved by using small, rapidly growing animals. Therefore, a large animal model remains needed to determine the ideal conditions and surgical technique to ensure long-term autograft remodeling and valve function. We set out to develop an ovine model of the Ross procedure performed as a freestanding root replacement, acknowledging that the sheep's specific anatomy and the setting of an animal laboratory would mandate several modifications in surgical strategy. This article describes the development, surgical technique and early outcomes of our animal model while highlighting opportunities for further research.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Piet Claus
- Cardiovascular Imaging and Dynamics, KU Leuven, Leuven, Belgium
| | | | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
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Mazine A, El-Hamamsy I. The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques. Ann Cardiothorac Surg 2021; 10:463-475. [PMID: 34422558 DOI: 10.21037/acs-2021-rp-25] [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: 01/21/2021] [Accepted: 06/10/2021] [Indexed: 11/06/2022]
Abstract
The Ross procedure is the best operation to treat aortic stenosis (AS) in young and middle-aged adults. However, its role in non-repairable aortic regurgitation (AR) remains debated since many historical series have reported an increased risk of pulmonary autograft dilatation and subsequent need for reintervention in these patients. Some have attributed these findings to an unrecognized and poorly characterized inherited genetic defect that prevents adaptive remodelling of the pulmonary autograft. Herein, we review the contemporary evidence surrounding the use of the Ross procedure in young adults with AR and put forth the argument that with proper technical refinements, the Ross procedure may still be the best operation to treat these patients. We believe that by tailoring the operation to the patient's anatomy and ensuring strict postoperative blood pressure control, one can achieve excellent results with the Ross procedure, including in this challenging patient population.
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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18
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Abeln KB, Chauvette V, Poirier N, Matsushima S, El-Hamamsy I, Schäfers HJ. Ross operation after failure of aortic valve repair. Ann Cardiothorac Surg 2021; 10:476-484. [PMID: 34422559 DOI: 10.21037/acs-2020-rp-19] [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: 09/10/2020] [Accepted: 01/22/2021] [Indexed: 11/06/2022]
Abstract
Background Repair failure remains one of the most important complications of aortic valve reconstruction. Young patients might benefit from a Ross procedure in such a scenario, provided it can be performed safely and with adequate durability. The aim of this study was to assess the safety and clinical outcomes of a Ross operation following a failed repair. Methods Between 1996 and 2019, 80 patients (male, 76%; mean age, 31±13 years) underwent a Ross procedure after a median of 6.6 (1.7-15.9) years following an initial aortic valve repair. The previous valve repair was performed for unicuspid (53%), bicuspid (39%), tricuspid (7%), and quadricuspid morphology (1%). Median follow-up after the Ross operation was 2.8 (0.964-13.25) years, mean 5±5 years (92% complete). Results Median cardiopulmonary bypass and cross-clamp times were 144 [106-154] minutes and 98 [79-113] minutes, respectively. Thirty-two patients (40%) required a concomitant procedure, most commonly, an ascending aortic replacement (n=23). There were no peri-operative deaths, myocardial infarctions, or neurological complications. There was one late death from a non-cardiac cause. At 10 years, overall survival was 99%±1%, similar to that of an age- and gender-matched population. Nine patients required re-intervention after their Ross procedure (five on the autograft and four on the pulmonary conduit). The autograft re-interventions were valve-sparing procedures in all patients. The cumulative incidence of re-intervention on the autograft at 8 years was 5.1%±3.1%. Conclusions The stepwise strategy of an initial valve repair followed by Ross operation represents a safe and valid option for failed aortic valve repair. It is associated with low peri-operative morbidity. Mid-term survival is excellent, similar to that of a matched general population. The probability of re-intervention after the Ross procedure appears similar to that of a primary Ross operation, deeming it a warranted consideration in cases of failed aortic valve repair.
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Affiliation(s)
- Karen B Abeln
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg (Saar), Germany
| | - Vincent Chauvette
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montreal, Montreal, Canada
| | - Nancy Poirier
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montreal, Montreal, Canada
| | | | - Ismail El-Hamamsy
- Department of Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, NY, USA
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg (Saar), Germany
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19
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Hage A, Hage F, Valdis M, Guo L, Chu MWA. The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease. Ann Cardiothorac Surg 2021; 10:454-462. [PMID: 34422557 DOI: 10.21037/acs-2021-rp-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
While aortic valve repair remains the ideal intervention to restore normal valvular function, the optimal aortic valve substitute for patients with a non-repairable aortic valve remains an ongoing subject for debate. In particular, younger patients with a non-repairable valve represent a unique challenge because of their active lifestyle and long life expectancy, which carries a higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike prosthetic or homograft aortic valve replacement (AVR), provides an expected survival equivalent to that of the age and gender-matched general population. Contemporary data has shown that the Ross procedure can be performed safely in centers with expertise, and is associated with improved valvular durability, hemodynamics and quality of life.
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Affiliation(s)
- Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Fadi Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Matthew Valdis
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Linrui Guo
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
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20
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Lenoir M, Bouhout I, Jelassi A, Cartier R, Poirier N, El-Hamamsy I, Demers P. Del Nido cardioplegia versus blood cardioplegia in adult aortic root surgery. J Thorac Cardiovasc Surg 2021; 162:514-522.e2. [DOI: 10.1016/j.jtcvs.2020.01.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 11/26/2022]
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21
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Chauvette V, Bouhout I, Lefebvre L, Tarabzoni M, Chamberland MÈ, Poirier N, Demers P, Chu MWA, Perron J, El-Hamamsy I. The Ross procedure is a safe and durable option in adults with infective endocarditis: a multicentre study. Eur J Cardiothorac Surg 2021; 58:537-543. [PMID: 32236477 DOI: 10.1093/ejcts/ezaa078] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/06/2020] [Accepted: 02/12/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Surgical treatment of infective endocarditis (IE) remains a challenge. The Ross procedure offers the benefit of a living substitute in the aortic position but it is a more complex operation which may lead to increased operative risk. The aim of this study was to assess the safety and late outcomes of the Ross procedure for the treatment of active IE. METHODS From 2000 to 2019, a total of 31 consecutive patients underwent a Ross procedure to treat active IE (mean age 43 ± 12 years, 84% male). All patients were followed up prospectively. Four patients (13%) were intravenous (IV) drug users and 6 patients (19%) had prosthetic IE. The most common infective organism was Streptococcus (58%). Median follow-up was 3.5 (0.9-4.5) years and 100% complete. RESULTS There were no in-hospital deaths. One patient suffered a postoperative stroke (3%) and 1 patient (3%) required reintervention for bleeding. Three patients had a new occurrence endocarditis: 2 patients were limited to the pulmonary homograft and successfully managed with IV antibiotics, whereas 1 IV drug user patient developed concomitant autograft and homograft endocarditis. Overall, cumulative incidence of IE recurrence was 13 ± 8% at 8 years. The cumulative incidence for autograft endocarditis was 5 ± 4% at 8 years. Two patients (6%) died during follow-up, both from drug overdoses. At 8 years, actuarial survival was 88 ± 8%. CONCLUSIONS In selected patients with IE, the Ross procedure is a safe and reasonable alternative with good mid-term outcomes. Freedom from recurrent infection on the pulmonary autograft is excellent, labelporting the notion that a living valve in the aortic position provides good resistance to infection. Nevertheless, in IV drug user patients, pulmonary homograft endocarditis remains a challenge. Continued follow-up is needed to ascertain the long-term benefits of this approach.
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Affiliation(s)
- Vincent Chauvette
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Ismail Bouhout
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Laurence Lefebvre
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Mohammed Tarabzoni
- Department of Cardiac Surgery, London Health Sciences Center, London, ON, Canada
| | - Marie-Ève Chamberland
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, QC, Canada
| | - Nancy Poirier
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Philippe Demers
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Michael W A Chu
- Department of Cardiac Surgery, London Health Sciences Center, London, ON, Canada
| | - Jean Perron
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec, QC, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada.,Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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De Backer O, Wong I, Wilkins B, Carranza CL, Søndergaard L. Patient-Tailored Aortic Valve Replacement. Front Cardiovasc Med 2021; 8:658016. [PMID: 33969021 PMCID: PMC8096928 DOI: 10.3389/fcvm.2021.658016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/19/2021] [Indexed: 11/25/2022] Open
Abstract
Contemporary surgical and transcatheter aortic valve interventions offer effective therapy for a broad range of patients with severe symptomatic aortic valve disease. Both approaches have seen significant advances in recent years. Guidelines have previously emphasized ‘surgical risk’ in the decision between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR), although this delineation becomes increasingly obsolete with more evidence on the effectiveness of TAVR in low surgical risk candidates. More importantly, decisions in tailoring aortic valve interventions should be patient-centered, accounting not only for operative risk, but also anatomy, lifetime management and specific co-morbidities. Aspects to be considered in a patient-tailored aortic valve intervention are discussed in this article.
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Affiliation(s)
- Ole De Backer
- Department of Cardiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Ivan Wong
- Department of Cardiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | - Ben Wilkins
- Department of Cardiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark
| | | | - Lars Søndergaard
- Department of Cardiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark
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The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5547342. [PMID: 33937396 PMCID: PMC8060091 DOI: 10.1155/2021/5547342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022]
Abstract
The Ross procedure has long been seen as an optimal operation for a select few. The detractors of it highlight the issue of an additional harvesting of the pulmonary artery, subjecting the native PA to systemic pressures and the need for reintervention as reasons to avoid it. However, the PA is a living tissue and capable of adapting and remodeling to growth. We therefore review the current evidence available to discuss the indications, contraindications, harvesting techniques, and modifications in a state-of-the-art narrative review of the PA as an aortic conduit. Due to the lack of substantial well-designed randomized controlled trials (RCTs), we also highlight the areas of need to reiterate the importance of the Ross procedure as part of the surgical armamentarium.
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24
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El-Hamamsy I, Warnes CA, Nishimura RA. The Ross Procedure in Adults: The Ideal Aortic Valve Substitute? J Am Coll Cardiol 2021; 77:1423-1425. [PMID: 33736824 DOI: 10.1016/j.jacc.2021.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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25
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Chauvette V, Bouhout I, Tarabzoni M, Wong D, Bozinovski J, Chu MW, El-Hamamsy I, Lefebvre L, Poirier N, Cartier R, Demers P, Halim MA. The Ross procedure in patients older than 50: A sensible proposition? J Thorac Cardiovasc Surg 2020; 164:835-844.e5. [DOI: 10.1016/j.jtcvs.2020.09.121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/18/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
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26
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Tam DY, Wijeysundera HC, Ouzounian M, Fremes SE. The Ross procedure versus mechanical aortic valve replacement in young patients: a decision analysis. Eur J Cardiothorac Surg 2020; 55:1180-1186. [PMID: 30535102 DOI: 10.1093/ejcts/ezy414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/17/2018] [Accepted: 10/25/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our goal was to determine the range of perioperative mortality rates associated with the Ross procedure that results in a life expectancy similar to that seen with mechanical aortic valve replacement (mAVR) in young patients with aortic valve disease. METHODS A fully probabilistic Markov microsimulation model with 1000 outer loops and 10 000 inner loops was constructed to compare gain in life expectancy and quality-adjusted life years between the index treatment with the Ross procedure versus mAVR for a theoretical cohort of young patients with aortic valve disease. Inputs for early deaths and late complications (death, stroke, bleeding, reoperation) were obtained from a single-centre study of 208 propensity score matched patients. In the primary analysis, the perioperative mortality rate for the Ross procedure was varied by increments of 0.5% to determine its impact on life expectancy and quality-adjusted life years. A 2-way sensitivity analysis was conducted to determine simultaneously the impact of the Ross reoperation rate and Ross reoperative mortality rate on life expectancy. RESULTS Life expectancy was improved with the Ross procedure when the perioperative mortality rate with the Ross procedure was <2.5% and was equivalent to mAVR when the mortality rate was 2.5% to 5%. Similarly, when the perioperative mortality rate of the Ross procedure was between 4% and 5.5%, the quality-adjusted life years gained were similar between the Ross procedure and mAVR. Life expectancy was improved when the Ross procedure reoperative mortality rate was <7% at an incidence of Ross reoperations of 18% at 20 years. CONCLUSIONS Improved life expectancy can be expected with the Ross procedure when the operative mortality rate is less than 2.5%.
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Affiliation(s)
- Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Chauvette V, Bouhout I, Tarabzoni M, Pham M, Wong D, Whitlock R, Chu MWA, El-Hamamsy I. Pulmonary homograft dysfunction after the Ross procedure using decellularized homografts-a multicenter study. J Thorac Cardiovasc Surg 2020; 163:1296-1305.e3. [PMID: 32888704 DOI: 10.1016/j.jtcvs.2020.06.139] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/28/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Pulmonary homograft dysfunction is a limitation after the Ross procedure. Decellularized pulmonary homografts can potentially mitigate this complication. The aim of this study was to examine the incidence, predictors, progression, and morphology of pulmonary homograft dysfunction using data from the Canadian Ross Registry. METHODS From 2011 to 2019, 466 consecutive patients (mean age: 47 ± 12 years, 73% male) underwent a Ross procedure using a decellularized cryopreserved pulmonary homograft (SynerGraft SG; CryoKife, Kennesaw, Ga). Pulmonary homograft dysfunction was defined as any of the following: peak pulmonary gradient ≥30 mm Hg, pulmonary regurgitation >2, or pulmonary homograft reintervention. Patients meeting ≥1 of these criteria (n = 30) were compared with the rest of the cohort (n = 436). Median follow-up is 2.2 years (maximum = 8.5 years) and 99% complete (1176 patient-years). RESULTS The cumulative incidence of pulmonary homograft dysfunction was 11 ± 2% at 6 years. Pulmonary homograft stenosis was the most frequent presentation (n = 28 patients, 93%). Morphologically, stenosis occurred most often along the conduit (59%). Overall, 4 patients required homograft reintervention. At 6 years, the cumulative incidence of homograft reintervention was 3 ± 1%. The instantaneous risk was greatest in the first year after surgery (3.5%/year) and decreased to <1%/year thereafter. Patient age <45 years was the only independent risk factor associated with pulmonary homograft dysfunction (hazard ratio, 3.1, 95% confidence interval, 1.1-8.6, P = .03). CONCLUSIONS The use of decellularized cryopreserved pulmonary homografts results in a low incidence of dysfunction and reintervention after the Ross procedure. The risk is greater in the first postoperative year. Younger age is the only independent risk factor for pulmonary homograft dysfunction.
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Affiliation(s)
- Vincent Chauvette
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Ismail Bouhout
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Mohammed Tarabzoni
- Department of Cardiac Surgery, London Health Science Center, Western University, London, Ontario, Canada
| | - Magali Pham
- Department of Radiology, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Daniel Wong
- Department of Cardiac Surgery, Royal Columbian Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Whitlock
- Department of Cardiac Surgery, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael W A Chu
- Department of Cardiac Surgery, London Health Science Center, Western University, London, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada; Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY.
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28
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Chauvette V, Chamberland MÈ, El-Hamamsy I. A review of pulmonary autograft external support in the Ross procedure. Expert Rev Med Devices 2019; 16:981-988. [PMID: 31663385 DOI: 10.1080/17434440.2019.1685380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Although the Ross procedure offers several advantages over standard prosthetic AVR, its use remains limited. The risk of pulmonary autograft dilatation requiring reintervention remains one of the main concerns. Consequently, multiple techniques have been developed in attempt to mitigate this complication.Areas covered: This article reviews the incidence of pulmonary autograft dilatation, its risk factors and pathophysiology. The techniques of external pulmonary autograft support are discussed along with their respective advantages and limitations. Finally, future areas of research and developments are examined.Expert opinion: The risk of autograft dilatation is mainly prevalent in patients with aortic regurgitation and a dilated aortic annulus. In these selected patients, an external support may prevent dilatation of the autograft. However, any permanent support potentially restricts autograft root motion, mitigating some of the advantages associated with the Ross procedure. A bioresorbable matrix that could support the root during its initial adaptative phase could alleviate this problem. In our opinion, aggressive blood pressure control during the first postoperative year along with annular and sino-tubular junction support in selected patients provides optimal stability of autograft root dimensions while preserving root dynamics. Serial imaging and clinical follow-up are necessary to define the role of these various strategies.
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Affiliation(s)
- Vincent Chauvette
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
| | | | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
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Mazine A, Rocha RV, El-Hamamsy I, Ouzounian M, Yanagawa B, Bhatt DL, Verma S, Friedrich JO. Ross Procedure vs Mechanical Aortic Valve Replacement in Adults: A Systematic Review and Meta-analysis. JAMA Cardiol 2019; 3:978-987. [PMID: 30326489 DOI: 10.1001/jamacardio.2018.2946] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The ideal aortic valve substitute in young and middle-aged adults remains unknown. Objective To compare long-term outcomes between the Ross procedure and mechanical aortic valve replacement in adults. Data Sources The Ovid versions of MEDLINE and EMBASE classic (January 1, 1967, to April 26, 2018; search performed on April 27, 2018) were screened for relevant studies using the following text word search in the title or abstract: ("Ross" OR "autograft") AND ("aortic" OR "mechanical"). Study Selection All randomized clinical trials and observational studies comparing the Ross procedure to the use of mechanical prostheses in adults undergoing aortic valve replacement were included. Studies were included if they reported any of the prespecified primary or secondary outcomes. Studies were excluded if no clinical outcomes were reported or if data were published only as an abstract. Citations were screened in duplicate by 2 of the authors, and disagreements regarding inclusion were reconciled via consensus. Data Extraction and Synthesis This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. Data were independently abstracted by 3 reviewers and pooled using a random-effects model. Main Outcomes and Measures The prespecified primary outcome was all-cause mortality. Results The search identified 2919 reports, of which 18 studies (3516 patients) met inclusion criteria, including 1 randomized clinical trial and 17 observational studies, with a median average follow-up of 5.8 (interquartile range, 3.4-9.2) years. Analysis of the primary outcome showed a 46% lower all-cause mortality in patients undergoing the Ross procedure compared with mechanical aortic valve replacement (incidence rate ratio [IRR], 0.54; 95% CI, 0.35-0.82; P = .004; I2 = 28%). The Ross procedure was also associated with lower rates of stroke (IRR, 0.26; 95% CI, 0.09-0.80; P = .02; I2 = 8%) and major bleeding (IRR, 0.17; 95% CI, 0.07-0.40; P < .001; I2 = 0%) but higher rates of reintervention (IRR, 1.76; 95% CI, 1.16-2.65; P = .007; I2 = 0%). Conclusions and Relevance Data from primarily observational studies suggest that the Ross procedure is associated with lower all-cause mortality compared with mechanical aortic valve replacement. These findings highlight the need for a large, prospective randomized clinical trial comparing long-term outcomes between these 2 interventions.
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo V Rocha
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Maral Ouzounian
- Department of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Department of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Subodh Verma
- Department of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Department of Critical Care Medicine, St Michael's Hospital, Toronto, Ontario, Canada
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Nappi F, Singh SSA, Lusini M, Nenna A, Gambardella I, Chello M. The use of allogenic and autologous tissue to treat aortic valve endocarditis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:491. [PMID: 31700927 DOI: 10.21037/atm.2019.08.76] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The surgical treatment of aortic valve endocarditis (AVE) is generally performed using conventional mechanical or biological xenograft prosthesis, with limited use of aortic homograft (Ao-Homo) or pulmonary autograft (PA). Clinical evidence has demonstrated a clear contradiction between the proven benefits of Ao-Homo and PA in the context of infection and the very limited use of allogenic or autologous tissue in everyday clinical practice. This review aims to summarize the most recent and relevant literature in order to foster the scientific debate on the use of the use of allogenic and autologous tissue to treat AVE. The decisional process of the Heart Team should also include the preferences of the patient, his/her family, the general cardiologist or primary care physician. The use of allogenic or autologous valve substitute is beneficial if there is a high risk of recurrence of infection, avoiding extensive adhesiolysis and debridement of synthetic material. In any case, those procedures should be performed by highly trained centers to optimize outcomes.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, Paris, France
| | | | - Mario Lusini
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Bouhout I, Ghoneim A, Tousch M, Stevens LM, Semplonius T, Tarabzoni M, Poirier N, Cartier R, Demers P, Guo L, Chu MWA, El-Hamamsy I. Impact of a tailored surgical approach on autograft root dimensions in patients undergoing the Ross procedure for aortic regurgitation†. Eur J Cardiothorac Surg 2019; 56:959-967. [DOI: 10.1093/ejcts/ezz105] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The Ross procedure in patients with aortic regurgitation (AR) has been associated with increased autograft dilatation and late reintervention. The aim of this study was to evaluate the impact of a tailored approach aimed at mitigating that risk on early changes in autograft root dimensions following the Ross procedure in patients with AR.
METHODS
From 2011 to 2018, 241 consecutive patients underwent a Ross procedure with >1 year of follow-up [46 (7) years]. Aortic root dimensions were prospectively measured on serial echocardiograms. Patients with aortic stenosis group (n = 171; 71%) were compared to those with AR or mixed aortic disease (AR group) (n = 70; 29%). Mean length of follow-up was 29 ± 11 months (100% complete). Changes in aortic dimensions were analysed using mixed-effect models.
RESULTS
At 4 years, mean indexed diameters of the annulus, sinuses of Valsalva and the sinotubular junction in the AR group were 12.3 (0.2) mm/m2, 20.0 (0.4) mm/m2 and 16.3 (0.9) mm/m2, respectively, vs 11.9 (0.2), 18.4 (0.3) and 15.5 (0.5) in the aortic stenosis group. Overall, there were no significant differences in the rates of autograft annulus, sinuses of Valsalva and sinotubular junction dimension changes between the aortic stenosis and AR groups up to 4 years after surgery (P = 0.55, P = 0.12, P = 0.59 and P = 0.48, respectively).
CONCLUSIONS
Use of a tailored surgical approach, combined with a strict blood pressure control, appears to mitigate clinically significant early dilatation of the autograft root following a Ross procedure in patients with AR. Further follow-up is needed to determine if this will translate into a lower incidence of long-term reintervention.
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Affiliation(s)
- Ismail Bouhout
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Aly Ghoneim
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Michael Tousch
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Louis Mathieu Stevens
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Trevor Semplonius
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Mohammed Tarabzoni
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Nancy Poirier
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Raymond Cartier
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Philippe Demers
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Linrui Guo
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Michael W A Chu
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
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Mazine A, El-Hamamsy I, Verma S, Peterson MD, Bonow RO, Yacoub MH, David TE, Bhatt DL. Ross Procedure in Adults for Cardiologists and Cardiac Surgeons. J Am Coll Cardiol 2018; 72:2761-2777. [DOI: 10.1016/j.jacc.2018.08.2200] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/19/2018] [Indexed: 01/07/2023]
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