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Nguyen SN, Bouhout I, Singh S, Vinogradsky AV, Chung MM, Sevensky R, Kalfa DM, Bacha EA, Goldstone AB. Long-term autograft dilation and durability after the Ross procedure are similar in infants, children, and adolescents with primary aortic stenosis. J Thorac Cardiovasc Surg 2024; 168:1182-1191.e3. [PMID: 38266984 DOI: 10.1016/j.jtcvs.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 11/24/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Autograft durability and remodeling are thought to be superior in younger pediatric patients after the Ross operation. We sought to delineate the fate of autografts across the pediatric age spectrum in patients with primary aortic stenosis (AS). METHODS We retrospectively reviewed patients age ≤18 years with primary AS who underwent the Ross operation between 1993 and 2020. Patients were categorized by age. The primary endpoint was autograft dimensional change, and secondary endpoints were severe neo-aortic insufficiency (AI) and autograft reintervention. RESULTS A total of 119 patients underwent the Ross operation, including 37 (31.1%) in group I (age <18 months), 24 (20.2%) in group II (age 18 months-8 years), and 58 (48.7%) in group III (age 8-18 years). All groups exhibited similar annular growth rates within the first 5 postoperative years, followed by a collective decrease in annulus growth rates from year 5 to year 10. Group III experienced rapid sinus dilation in the first 5 years, followed by stabilization of the sinus z-score from year 5 to year 10, whereas groups I and II demonstrated stable sinus z-scores over 10 years. There were 4 early deaths (3.4%) and 2 late deaths (1.7%) at a median follow-up of 8.1 years (range, 0.01-26.3 years). At 15 years, the incidences of severe neo-AI (0.0 ± 0.0% vs 0.0 ± 0.0% vs 3.9 ± 3.9%; P = .52) and autograft reintervention (8.4 ± 6.0% vs 0.0 ± 0.0% vs 2.4 ± 2.4%; P = .47) were similar in the 3 groups. CONCLUSIONS Age at the time of Ross operation for primary AS does not influence long-term autograft remodeling or durability. Other physiologic or technical factors are likely greater determinants of autograft fate.
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Affiliation(s)
- Stephanie N Nguyen
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Ismail Bouhout
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Sameer Singh
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Alice V Vinogradsky
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Megan M Chung
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Riley Sevensky
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - David M Kalfa
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Emile A Bacha
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Andrew B Goldstone
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY.
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Markham GH, Brown JW, Wenos CD, Jensen MO, Jensen HK, Markham LW, Herrmann JL. Ross Confers More Favorable Left Ventricular Remodeling Compared With Mechanical Aortic Valve Replacement. World J Pediatr Congenit Heart Surg 2024:21501351241266122. [PMID: 39196650 DOI: 10.1177/21501351241266122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Abstract
Background: Aortic valve disease results in left ventricular (LV) dilation and/or hypertrophy. Valve intervention may improve, but not normalize flow dynamics. We hypothesized that LV remodeling would be more favorable following the Ross procedure versus mechanical aortic valve replacement (mAVR). Methods: Patients who were 18 to 50 years of age and underwent Ross or mAVR from 2000 to 2016 at a single institution were retrospectively reviewed. Propensity score matching was performed and yielded 27 well-matched pairs. Demographics and echocardiographic variables of LV morphology and wall thickness were collected. Those with > mild residual valve disease were excluded. Primary endpoints included LV morphology. T test and Fisher exact test analysis were used for statistical comparison. Results: Average age at operation (Ross 35.3 ± 10.2 vs mAVR 37.3 ± 8.9 years) did not differ. Indication for operation was similar between groups. Preoperative echocardiographic variables did not differ. At average follow-up duration (Ross 7.9 ± 2.4 vs mAVR 7.3 ± 2.4 years), wall thickness was significantly smaller for Ross compared with mAVR (P = .00715). Only 4/27 (15%) of mAVR patients had normalized LV parameters compared with 16/27 (59%) of Ross patients (P = .000813). Residual hypertrophy was the most common long-term abnormality for mAVR. Conclusion: Following aortic valve replacement with the Ross procedure or mechanical aortic valve prosthesis, the Ross conferred more favorable LV remodeling compared with mAVR. Future directions include analyzing longer follow-up to determine if patterns persist and the impact on cardiac morbidity and mortality.
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Affiliation(s)
- Garrett H Markham
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA
| | - John W Brown
- Division of Congenital Cardiac Surgery, Department of Surgery, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chelsea D Wenos
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Morten O Jensen
- Department of Biomedical Engineering, Department of Surgery, University of Arkansas for Medical Sciences, University of Arkansas, Little Rock, AR, USA
| | - Hanna K Jensen
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Larry W Markham
- Division of Cardiology, Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Division of Congenital Cardiac Surgery, Department of Surgery, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Greenberg JW, Argo M, Ashfaq A, Luxford JC, Fuentes-Baldemar AA, Kalustian AB, Pena-Munoz SV, Barron DJ, Mertens LL, Husain SA, Heinle JS, Goldie LC, Orr Y, Ayer J, Mavroudis CD, Fuller SM, Morales DLS, Hill GD, Winlaw DS. Long-term outcomes following the Ross procedure in neonates and infants: A multi-institutional analysis. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00552-X. [PMID: 38971401 DOI: 10.1016/j.jtcvs.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/03/2024] [Accepted: 06/15/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVES For neonates and infants with aortic valve pathology, the Ross procedure historically has been associated with high rates of morbidity and mortality. Data regarding long-term durability are lacking. METHODS The international, multi-institutional Ross Collaborative included 6 tertiary care centers. Infants who underwent a Ross operation between 1996 and 2016 (allowing a minimum 5 years of follow-up) were retrospectively identified. Serial echocardiograms were examined to study evolution in neoaortic size and function. RESULTS Primary diagnoses for the 133 patients (n = 30 neonates) included isolated aortic stenosis (14%, n = 19), Shone complex (14%, n = 19), and aortic stenosis plus other (excluding Shone complex; n = 95, 71%), including arch obstruction (n = 55), left ventricular hypoplasia (n = 9), and mitral disease (moderate or greater stenosis or regurgitation, n = 31). At the time of the Ross procedure, median age was 96 days (interquartile range, 36-186), and median weight was 4.4 kg (3.6-6.5). In-hospital mortality occurred in 13 of 133 patients (10%) (4/30 [13%] neonates). Postdischarge mortality occurred in 10 of 120 patients (8%) at a median of 298 days post-Ross. Post-Ross neoaortic dilatation occurred, peaking at 4 to 5 SDs above normal at 2 to 3 years before returning to near-baseline z-score at a median follow-up of 11.5 [6.4-17.4] years. Autograft/left ventricular outflow tract reintervention was required in 5 of 120 patients (4%) at a median of 10.3 [4.1-12.8] years. Freedom from moderate or greater neoaortic regurgitation was 86% at 15 years. CONCLUSIONS Neonates and infants experience excellent postdischarge survival and long-term freedom from autograft reintervention and aortic regurgitation after the Ross. Neoaortic dilatation normalizes in this population in the long-term. Increased consideration should be given to Ross in neonates and infants with aortic valve disease.
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Affiliation(s)
| | - Madison Argo
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Awais Ashfaq
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | | | - David J Barron
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc L Mertens
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | - Yishay Orr
- The Children's Hospital at Westmead, Sydney, Australia
| | - Julian Ayer
- The Children's Hospital at Westmead, Sydney, Australia
| | | | | | | | - Garick D Hill
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Winlaw
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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4
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Starnes VA, Elsayed RS, Cohen RG, Olds AP, Bojko MM, Mack WJ, Cutri RM, Baertsch HC, Baker CJ, Kumar SR, Bowdish ME. Long-term outcomes with the pulmonary autograft inclusion technique in adults with bicuspid aortic valves undergoing the Ross procedure. J Thorac Cardiovasc Surg 2023; 165:43-52.e2. [PMID: 33685733 DOI: 10.1016/j.jtcvs.2021.01.101] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare outcomes with wrapped (pulmonary autograft inclusion) versus unwrapped techniques in adults with bicuspid aortic valves undergoing the Ross procedure. METHODS Between 1992 and 2019, 129 adults with bicuspid aortic valves (aged ≥18 years) underwent the Ross procedure by a single surgeon. Patients were divided into those without autograft inclusion (unwrapped, n = 71) and those with autograft inclusion (wrapped, n = 58). Median follow-up was 10.3 years (interquartile range, 3.0-16.8 years). Need for autograft reintervention was analyzed using competing risks. RESULTS Pre- and intraoperative characteristics as well as 30-day morbidity or mortality did not differ between cohorts. Survival at 1, 5, and 10 years, respectively, was 97.2%, 97.2%, and 95.6% in the unwrapped cohort and 100%, 100%, and 100% in the wrapped cohort (P = .15). Autograft valve failure occurred in 25 (35.2%) of the unwrapped and 3 (5.2%) of the wrapped patients. Competing risks analysis demonstrated the wrapped cohort to have a lower need for autograft reintervention (subhazard ratio, 0.28, 95% confidence interval, 0.08-0.91; P = .035). The cumulative incidence of autograft reintervention (death as a competing outcome) at 1, 5, and 10 years, respectively, was 10.2%, 14.9%, and 26.8% in the unwrapped cohort and 4.0%, 4.0%, and 4.0% in the wrapped cohort. CONCLUSIONS In adults with bicuspid aortic valves, the Ross procedure with pulmonary autograft inclusion stabilizes the aortic root preventing dilatation and reduces the need for reoperation. The autograft inclusion technique allows the Ross procedure to be performed in this population with excellent long-term outcomes.
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Affiliation(s)
- Vaughn A Starnes
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Ramsey S Elsayed
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Robbin G Cohen
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Anna P Olds
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Markian M Bojko
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Raffaello M Cutri
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Hans C Baertsch
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Craig J Baker
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Michael E Bowdish
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif; Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.
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5
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Wenos CD, Herrmann JL, Timsina LR, Patel PM, Fehrenbacher JW, Brown JW. Perioperative and long-term outcomes of Ross versus mechanical aortic valve replacement. J Card Surg 2022; 37:2963-2971. [PMID: 35989510 PMCID: PMC9542516 DOI: 10.1111/jocs.16831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 03/24/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
Background The ideal aortic valve replacement strategy in young‐ and middle‐aged adults remains up for debate. Clinical practice guidelines recommend mechanical prostheses for most patients less than 50 years of age undergoing aortic valve replacement. However, risks of major hemorrhage and thromboembolism associated with long‐term anticoagulation may make the pulmonary autograft technique, or Ross procedure, a preferred approach in select patients. Methods Data were retrospectively collected for patients 18–50 years of age who underwent either the Ross procedure or mechanical aortic valve replacement (mAVR) between January 2000 and December 2016 at a single institution. Propensity score matching was performed and yielded 32 well‐matched pairs from a total of 216 eligible patients. Results Demographic and preoperative characteristics were similar between the two groups. Median follow‐up was 7.3 and 6.9 years for Ross and mAVR, respectively. There were no early mortalities in either group and no statistically significant differences were observed with respect to perioperative outcomes or complications. Major hemorrhage and stroke events were significantly more frequent in the mAVR population (p < .01). Overall survival (p = .93), freedom from reintervention and valve dysfunction free survival (p = .91) were equivalent. Conclusions In this mid‐term propensity score‐matched analysis, the Ross procedure offers similar perioperative outcomes, freedom from reintervention or valve dysfunction as well as overall survival compared to traditional mAVR but without the morbidity associated with long‐term anticoagulation. At specialized centers with sufficient expertize, the Ross procedure should be strongly considered in select patients requiring aortic valve replacement.
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Affiliation(s)
- Chelsea D Wenos
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeremy L Herrmann
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Divison of Pediatric Cardiothoracic Surgery, Riley Children's Health, Indiana University Health, Indianapolis, Indiana, USA
| | - Lava R Timsina
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Surgery, Indiana University School of Medicine, Center for Outcomes Research in Surgery, Indianapolis, Indiana, USA
| | - Parth M Patel
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John W Fehrenbacher
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indianapolis, Indiana, USA
| | - John W Brown
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Divison of Pediatric Cardiothoracic Surgery, Riley Children's Health, Indiana University Health, Indianapolis, Indiana, USA
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6
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DeCampli WM. Will we work out the Ross dilemma in 30 minutes?-Or 30 years? World J Pediatr Congenit Heart Surg 2022; 13:175-177. [PMID: 35238699 DOI: 10.1177/21501351221075839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- William M DeCampli
- Division of Cardiovascular Surgery, Arnold Palmer Hospital for Children, Orlando, FL, USA; Department of Clinical Sciences, University of Central Florida College of Medicine, Orlando, FL, USA
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Luxford JC, Ayer JG, Betts K, Salve GG, Orr Y, Chard RB, Roberts P, Sholler GF, Winlaw DS. The Ross/Ross-Konno procedure in infancy is a safe and durable solution for aortic stenosis. J Thorac Cardiovasc Surg 2021; 163:365-375. [PMID: 34600763 DOI: 10.1016/j.jtcvs.2021.06.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/02/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of this study was to characterize early and midterm outcomes after the Ross/Ross-Konno procedure performed in infancy for severe aortic valve disease. METHODS Between January 1995 and December 2018, 35 infants younger than 1 year (13 neonates) underwent a Ross/Ross-Konno procedure. Patients were followed up to a median of 4.1 years (interquartile range [IQR], 2.6-9.5). Primary outcome measures were survival, early morbidity, freedom from reintervention and long-term functional and echocardiographic status. RESULTS Median age at operation was 49 days (IQR, 17-135) and weight was 4 kg (IQR, 3.4-5.2). Thirty-one (89%) had undergone a previous procedure, including balloon valvuloplasty in 26 (74%). Thirty (86%) required annular enlargement (Konno incision). Five required concomitant aortic arch surgery (2 neonates, 3 infants). There were no early deaths, and 1 late death at 18 months. Freedom from reoperation was 85% (95% confidence interval [CI], 68%-93%) at 1 year, 76% (95% CI, 54%-88%) at 5 years, and 62% (95% CI, 36%-79%) at 10 years. One modified Konno was performed at 5 years after a Ross in infancy. Ten right ventricle to pulmonary artery conduits have required reintervention (2 percutaneous pulmonary valve implantations). One child required a permanent pacemaker for complete heart block. At latest follow-up, 32 (94%) of 34 survivors were asymptomatic. There was no significant change in neoaortic Z-scores between 6 weeks and latest follow-up. CONCLUSIONS The neonatal and infant Ross/Ross-Konno procedure can be performed with low mortality and achieves a stable left ventricular outflow tract. Significant early morbidity reflects the preoperative condition of the patients but definitive surgery of this type can be considered as a primary approach.
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Affiliation(s)
- Jack C Luxford
- Sydney Medical School, University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia.
| | - Julian G Ayer
- Sydney Medical School, University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Kim Betts
- School of Public Health, Curtin University, Perth, Australia
| | - Gananjay G Salve
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Yishay Orr
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Richard B Chard
- Sydney Medical School, University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Philip Roberts
- Sydney Medical School, University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Gary F Sholler
- Sydney Medical School, University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - David S Winlaw
- Sydney Medical School, University of Sydney, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Moroi MK, Bacha EA, Kalfa DM. The Ross procedure in children: a systematic review. Ann Cardiothorac Surg 2021; 10:420-432. [PMID: 34422554 DOI: 10.21037/acs-2020-rp-23] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/10/2021] [Indexed: 12/20/2022]
Abstract
Background The Ross procedure involves autograft transplantation of the native pulmonary valve into the aortic position and reconstruction of the right ventricular outflow tract (RVOT) with a homograft. The operation offers the advantages of a native valve with excellent hemodynamic performance, the avoidance of anticoagulation, and growth potential. Conversely, the operation is technically demanding and imposes the risk of turning single-valve disease into double-valve disease. This systematic review reports outcomes of pediatric patients undergoing the Ross procedure. Methods An electronic search identified studies reporting outcomes on pediatric patients (mean age <18 years, max age <21 years) undergoing the Ross procedure. Long-term outcomes, including early mortality, late mortality, sudden unexpected unexplained death, reoperation due to failure of the pulmonary autograft or RVOT reconstruction, thromboembolic events, bleeding events, and endocarditis-related complications, were evaluated. Results Upon review of 2,035 publications, 30 studies and 3,156 pediatric patients were included. Patients had a median age of 9.5 years and median follow-up period of 5.7 years. Early mortality rates varied from 0.0 to 17.0% and were increased in the neonatal population. Late mortality rates were much lower (0.04-1.83%/year). Reoperation due to pulmonary autograft failure occurred at rates of 0.37-2.81%/year and reoperation due to RVOT reconstruction failure was required at rates of 0.34-4.76%/year. Thromboembolic, bleeding, and endocarditis events were reported to occur at rates of 0.00-0.58, 0.00-0.39, and 0.00-1.68%/year, respectively. Conclusions The Ross operation offers a durable aortic valve replacement (AVR) option in the pediatric population that offers favorable survival, excellent hemodynamics, growth potential, decreased risk of complications, and avoidance of anticoagulation. Larger multi-institutional registries focusing on pediatric patients are necessary to provide more robust evidence to further support use of the Ross procedure in this population.
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Affiliation(s)
- Morgan K Moroi
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Emile A Bacha
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - David M Kalfa
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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9
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Porter A, Yu S, Lowery R, Fifer CG, Lu JC. Echocardiographic Findings Associated with Transplantation-Free Survival and Left Ventricular Systolic Function at Midterm Follow-Up after Ross Procedure in Infants with Critical Aortic Stenosis. J Am Soc Echocardiogr 2020; 34:522-528.e1. [PMID: 33385500 DOI: 10.1016/j.echo.2020.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Ross operation is an important option for children with critical aortic stenosis with residual disease, but operation in infancy is associated with significant morbidity and mortality. The aim of this study was to evaluate echocardiographic correlates of transplantation-free survival, reintervention, and left ventricular (LV) function in midterm follow-up. METHODS This retrospective, single-center study included all infants with critical aortic stenosis who underwent Ross by 1 year of age from January 2000 to September 2018. Serial echocardiograms were analyzed for LV ejection fraction (LVEF) and systolic and diastolic longitudinal strain. The primary outcome was mortality or transplantation; secondary outcomes were reintervention and abnormal LVEF (≤55%). RESULTS Among 40 infants (30 male [75%]; median age at Ross, 51 days) with median follow-up duration of 3.3 years (interquartile range, 1.0-9.4 years), the primary outcome was met in 11 (28%). Rates of transplantation-free survival was 79%, 77%, and 69% at 1, 5, and 10 years after Ross. Predictors of transplantation or death included neonatal surgery, cross-clamp time, and preoperative left atrial dilatation and lower LVEF. Median freedom from reintervention was 7.1 years after Ross, with no identified associations. LV longitudinal strain improved 1 year after Ross (-21.1 ± 3.8% vs -17.4 ± 5.1%, P = .02), although LVEF did not reach significance. Lower LVEF at 1 year was related to pre-Ross left atrial dilatation (P = .02), abnormal LVEF (P = .04), and lower early diastolic longitudinal strain rate (P = .03). LVEF remained stable 3 years after Ross. CONCLUSIONS Both transplantation-free survival and normalization of LV function after Ross in infancy are associated with preoperative LV systolic and diastolic measures, highlighting the prognostic value of echocardiography in this population. Further data are necessary in a larger, multicenter cohort to allow more precise risk stratification.
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Affiliation(s)
- Andrew Porter
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University, Atlanta, Georgia
| | - Sunkyung Yu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan
| | - Ray Lowery
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan
| | - Carlen G Fifer
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan
| | - Jimmy C Lu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, Michigan.
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10
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Kerr MM, Gourlay T. Design and numerical simulation for the development of an expandable paediatric heart valve. Int J Artif Organs 2020; 44:518-524. [PMID: 33300423 PMCID: PMC8366171 DOI: 10.1177/0391398820977509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Current paediatric valve replacement options cannot compensate for somatic growth, leading to an obstruction of flow as the child outgrows the prosthesis. This often necessitates an increase in revision surgeries, leading to legacy issues into adulthood. An expandable valve concept was modelled with an inverse relationship between annulus size and height, to retain the leaflet geometry without requiring additional intervention. Parametric design modelling was used to define certain valve parameter aspect ratios in relation to the base radius, Rb, including commissural radius, Rc, valve height, H and coaptation height, x. Fluid-structure simulations were subsequently carried out using the Immersed Boundary method to radially compress down the fully expanded aortic valve whilst subjecting it to diastolic and systolic loading cycles. Leaflet radial displacements were analysed to determine if valve performance is likely to be compromised following compression. Work is ongoing to optimise valvular parameter design for the paediatric patient cohort.
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Affiliation(s)
- Monica M Kerr
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK
| | - Terence Gourlay
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK
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Vanderveken E, Vastmans J, Verbelen T, Verbrugghe P, Famaey N, Verbeken E, Treasure T, Rega F. Reinforcing the pulmonary artery autograft in the aortic position with a textile mesh: a histological evaluation. Interact Cardiovasc Thorac Surg 2019; 27:566-573. [PMID: 29912400 DOI: 10.1093/icvts/ivy134] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/25/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The Ross procedure involves replacing a patient's diseased aortic valve with their own pulmonary valve. The most common failure mode is dilatation of the autograft. Various strategies to reinforce the autograft have been proposed. Personalized external aortic root support has been shown to be effective in stabilizing the aortic root in Marfan patients. In this study, the use of a similar external mesh to support a pulmonary artery autograft was evaluated. METHODS The pulmonary artery was translocated as an interposition autograft in the descending thoracic aortas of 10 sheep. The autograft was reinforced with a polyethylene terephthalate mesh (n = 7) or left unreinforced (n = 3). After 6 months, a computed tomography scan was taken, and the descending aorta was excised and histologically examined using the haematoxylin-eosin and Elastica van Gieson stains. RESULTS The autograft/aortic diameter ratio was 1.59 in the unreinforced group but much less in the reinforced group (1.11) (P < 0.05). A fibrotic sheet, variable in thickness and containing fibroblasts, neovessels and foreign body giant cells, was incorporated in the mesh. Histological examination of the reinforced autograft and the adjacent aorta revealed thinning of the vessel wall due to atrophy of the smooth muscle cells. Potential spaces between the vessel wall and the mesh were filled with oedema. CONCLUSIONS Reinforcing an interposition pulmonary autograft in the descending aorta with a macroporous mesh showed promising results in limiting autograft dilatation in this sheep model. Histological evaluation revealed atrophy of the smooth muscle cell and consequently thinning of the vessel wall within the mesh support.
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Affiliation(s)
- Emma Vanderveken
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Julie Vastmans
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Eric Verbeken
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Tom Treasure
- Clinical Operational Research Unit, UCL, London, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Etnel JR, Grashuis P, Huygens SA, Pekbay B, Papageorgiou G, Helbing WA, Roos-Hesselink JW, Bogers AJ, Mokhles MM, Takkenberg JJ. The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation. Circ Cardiovasc Qual Outcomes 2018; 11:e004748. [DOI: 10.1161/circoutcomes.118.004748] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jonathan R.G. Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Pepijn Grashuis
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Simone A. Huygens
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
- Erasmus School of Health Policy & Management, ErasmusUniversity Rotterdam, The Netherlands (S.A.H.)
| | - Begüm Pekbay
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Grigorios Papageorgiou
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands (G.P.)
| | - Willem A. Helbing
- Division of Cardiology, Department of Pediatrics, Erasmus University Medical Center, Sophia Children’s Hospital, Rotterdam, The Netherlands (W.A.H.)
| | - Jolien W. Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (J.W.R.-H.)
| | - Ad J.J.C. Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - M. Mostafa Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
| | - Johanna J.M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands (J.R.G.E., P.G., S.A.H., B.P., G.P., A.J.J.C.B., M.M.M., J.J.M.T.)
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Bouhout I, Ghoneim A, Poirier N, Cartier R, Demers P, Perrault LP, El-Hamamsy I. Impact of the Learning Curve on Early Outcomes Following the Ross Procedure. Can J Cardiol 2017; 33:493-500. [DOI: 10.1016/j.cjca.2016.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 10/27/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022] Open
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Ungerleider RM, Walsh M, Ootaki Y. A modification of the pulmonary autograft procedure to prevent late autograft dilatation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:38-42. [PMID: 24725715 DOI: 10.1053/j.pcsu.2014.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Although the pulmonary autograft procedure for aortic valve replacement is a commonly utilized option for children, its use is diminishing in adult-aged patients. One commonly cited concern is the tendency for the pulmonary autograft to dilate in the aortic position. This article reviews a technique we have used in 36 patients since October, 2004 that stabilizes the autograft so that it cannot dilate. There have been no operative or late deaths and the autograft has continued to function in 34 patients. Two patients have undergone autograft replacement because of early failure, which we believe was likely related to technical considerations in our early technique (first reported in the 2005 STCVS Pediatric Cardiac Surgery Annual). The technical modifications described in this article have produced a more reliable and reproducible technique and have not resulted in any autograft failures in our experience. One patient with Marfan's syndrome and a bicuspid aortic valve is symptom- and dilation-free 8 years post op, with no autograft or pulmonary homograft insufficiency, normal activity and a stable aortic root by serial echocardiography. Our results suggest that this technique might be applicable for selected adult patients in whom autograft growth is not necessary and for whom the risk of autograft dilatation would provide a reason to avoid a pulmonary autograft procedure.
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Affiliation(s)
| | - Michael Walsh
- Brenner Children's Hospital, Wake Forest University, Winston Salem, NC
| | - Yoshio Ootaki
- Brenner Children's Hospital, Wake Forest University, Winston Salem, NC
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Brown JW, Patel PM, Rodefeld MD, Turrentine MW. The Ross Operation in Adolescents. World J Pediatr Congenit Heart Surg 2013; 4:403-11. [DOI: 10.1177/2150135113505295] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: The pulmonary autograft aortic valve replacement (Ross AVR) is the AVR of choice for children below the teenage years. Recent literature has questioned the durability of the Ross AVR in older children and young adults that present predominantly with aortic regurgitation and a dilated aortic root. At our center, the Ross AVR has been an excellent choice for most children and young and middle-aged adults. The Ross AVR is an especially good choice in young females who plan on becoming pregnant. We reviewed our experience with the Ross AVR in older children and young adults (10-20 years old) and analyzed mortality, early and late complications, and the need for reoperation and compared it to non-Ross AVR patients of the same age group during the same time period. Methods: Between 1993 and 2013, 79 children and young adults, of which 19 were female, between the age of 10 and 20, mean of 16.0 ± 2.7 years, underwent the Ross AVR. Follow-up ranged from 1 month to 20 years with a mean of 6.9 ± 5.8 years. Patients with primary and/or predominant aortic regurgitation and a dilated aortic root and/or ascending aorta at any level were called the “primarily aortic insufficiency (AI) group” (PAIG); 38 (48%) met this criteria. Because we saw some pathologic root enlargement and/or progressive aortic regurgitation in our early Ross experience (1993-2000), we modified our technique and postoperative management in 2000; 51 (65%) of 79 patients underwent the modified technique while 28 underwent our original Ross root replacement technique. The modified technique included reinforcing the aortic valve annulus and sinotubular junction and resecting or replacing the ascending aorta if it was dilated (>30 mm). Twenty-six patients during this same time period and in the same age group underwent the non-Ross AVR with a mean age of 16.5 ± 2 years. Seven of these 26 non-Ross patients were female, and 16 (62%) presented with aortic regurgitation as their primary lesion. Results: The early mortality for the Ross group and the non-Ross group was 0% and 4%, respectively. Late mortality for the Ross group was 2.5% and 0% for the non-Ross group. Of the 28 patients, 14 (50%) receiving the early Ross operation prior to 2000 have required reoperations. Only three (5.9%) of the 51 patients done after 2000 have required surgical reintervention ( P <.01). In all, 11 (34%) of our Ross patients operated prior to 2000 and three (6%) after 2000 have required reintervention on their autografts. Patients in the PAIG had zero early and late deaths and a 16% rate of reoperation on the autograft compared to zero early and two late deaths and 20% rate of reoperation in patients not in the PAIG group ( P = .266 and .467 respectively). The actuarial survival for the Ross group at 5 (N = 42), 10 (N = 24), and 20 (N = 1) years was 100%, 97%, and 73% respectively. Survival for the non-Ross group at 5 (N = 18), 10 (N = 8), and 20 (N = 1) years was 96%, 96%, and 96%, respectively; this difference in survival was not statistically significant ( P =.90). Differences in survival without reoperation for both the groups were not statistically significant ( P =.55). When comparing patients who had the newer Ross AVR technique and the non-Ross AVR patients, there was a significantly lower incidence of late aortic stenosis (AS) with a resting gradient greater than 20 mm Hg, 0% versus 53% ( P <.001). Conclusion: The Ross AVR is the procedure of choice for adolescents requiring AVR who have a normal pulmonary valve. There was no difference between the outcomes in patients who were in the PAIG group compared to non-PAIG patients. There was no difference in survival without reoperation between the Ross AVR and the non-Ross AVR within the 10- to 20-year age group. The Ross AVR patients had lower incidences of nonoperative complications. The Ross AVR patients had excellent hemodynamic outcomes with a significantly lower incidence of late AS when compared to the non-Ross AVR group. Reports of 15- to 20-year survival for the Ross AVR are encouraging. Long-term follow-up is necessary in all patients with aortic valve disease regardless of the treatment modality.
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Affiliation(s)
- John W. Brown
- Department of Surgery, Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Parth M. Patel
- Department of Surgery, Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D. Rodefeld
- Department of Surgery, Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark W. Turrentine
- Department of Surgery, Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Hörer J, Kasnar-Samprec J, Charitos E, Stierle U, Bogers AJJC, Hemmer W, Hetzer R, Hübler M, Robinson DR, Sievers HH, Lange R. Patient Age at the Ross Operation in Children Influences Aortic Root Dimensions and Aortic Regurgitation. World J Pediatr Congenit Heart Surg 2013; 4:245-52. [DOI: 10.1177/2150135113485763] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The Ross operation provides the advantage of growth potential of the pulmonary autograft in the aortic position. However, development of autograft dilatation and regurgitation may occur. We sought to assess the progression of autograft diameters and aortic regurgitation (AR) with regard to patient age at the time of the Ross operation. Methods: Autograft echo dimensions from 48 children <16 years of age at the time of the Ross operation, who had follow-up echocardiograms at <20 years of age, were analyzed using hierarchical multilevel modeling. The z values of autograft dimensions were calculated according to the normal aortic dimensions. Mean follow-up was 5.1 ± 3.3 years. The mean age at the time of the Ross operation was 10.0 ± 4.3 years. Results: The mean z values of all patients showed a significant increase with follow-up time at the sinus (0.5 ± 0.1/year, P < .001) and the sinotubular junction (0.7 ± 0.2/year, P < .001) but not at the annulus (0.1 ± 0.1/year, P = .59). There was no significant difference in the z values of sinus and the sinotubular junction between younger and older children at implantation and with time. The initial annulus z value was significantly larger in younger children ( P < .0001), whereas the annual increase was significantly higher in older children ( P = .021). Age at operation has no impact on the initial AR grade ( P = .60). The AR tends to increase more quickly in older patients ( P = .040). Sinus and sinotubular junction dilate with time, regardless of patient age. Conclusions: Young children show larger initial annulus sizes than older children. However, annulus diameters tend to normalize in young children, whereas they increase in older children. Autograft regurgitation develops slowly, but significantly, and predominantly in older children. Stabilizing measures to prevent autograft root dilatation are warranted in adolescents, but they are not required in young children.
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Affiliation(s)
- Jürgen Hörer
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technische Universität München, Munich, Germany
| | - Jelena Kasnar-Samprec
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technische Universität München, Munich, Germany
| | - Efstratios Charitos
- Department of Cardiac Surgery, University Clinic Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Ulrich Stierle
- Department of Cardiac Surgery, University Clinic Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Ad J. J. C. Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | | | - Derek R. Robinson
- Department of Mathematics, School of Science and Technology, University of Sussex, Brighton, United Kingdom
| | - Hans H. Sievers
- Department of Cardiac Surgery, University Clinic Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technische Universität München, Munich, Germany
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Ruzmetov M, Geiss DM, Shah JJ, Buckley K, Fortuna RS. The Ross-Konno Is a High-Risk Procedure When Compared With the Ross Operation in Children. Ann Thorac Surg 2013; 95:670-5. [DOI: 10.1016/j.athoracsur.2012.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 08/06/2012] [Accepted: 08/14/2012] [Indexed: 11/30/2022]
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19
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Ross Root Dilation in Adult Patients: Is Preoperative Aortic Insufficiency Associated With Increased Late Autograft Reoperation? Ann Thorac Surg 2011; 92:74-81; discussion 81. [DOI: 10.1016/j.athoracsur.2011.02.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/02/2011] [Accepted: 02/07/2011] [Indexed: 11/23/2022]
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20
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Neoaortic Valve and Root Complex Evolution After Ross Operation in Infants, Children, and Adolescents. Ann Thorac Surg 2010; 90:1278-85. [DOI: 10.1016/j.athoracsur.2010.06.077] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 06/09/2010] [Accepted: 06/11/2010] [Indexed: 11/18/2022]
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21
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Hörer J, Hanke T, Stierle U, Takkenberg JJM, Bogers AJJC, Hemmer W, Rein JG, Hetzer R, Hübler M, Robinson DR, Sievers HH, Lange R. Neoaortic root diameters and aortic regurgitation in children after the Ross operation. Ann Thorac Surg 2009; 88:594-600; discussion 600. [PMID: 19632419 DOI: 10.1016/j.athoracsur.2009.04.077] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 04/20/2009] [Accepted: 04/22/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND For children who require aortic valve replacement, the Ross operation provides a unique advantage of growth potential of the pulmonary autograft in the aortic position. This study assessed the progression of autograft root diameters and its effect on aortic regurgitation (AR). METHODS Neoaortic echo dimensions from 48 children (<16 years) undergoing Ross operation who had follow-up echocardiograms before age 20 were analyzed (mean follow-up, 5.1 +/- 3.3 years). RESULTS The mean age at the time of the Ross operation was 10.0 +/- 4.3 years. Mean z values of the neoaortic annulus (1.5 +/- 0.4), sinus (2.5 +/- 0.4), and sinotubular junction (2.6 +/- 0.9) when the autograft was implanted were significantly larger compared with normal values (p < 0.001, all). The mean z values significantly increased with follow-up at the level of the sinus (0.5 +/- 0.1/year, p < 0.001) and the sinotubular junction (0.7 +/- 0.2, p < 0.001), but not at the level of the annulus (0.1 +/- 0.1, p = 0.59). AR increased with follow-up time (0.07 +/- 0.02 grade/year, p < 0.001). AR increased with sinotubular junction diameter (p = 0.028), but there was not significant evidence of an association with annulus diameter (p = 0.25) or sinus diameter (p = 0.40). CONCLUSIONS Children undergoing Ross operation have larger neoaortic root dimensions than healthy children. Growth of the annulus matches somatic growth. The diameters of the sinus and the sinotubular junction increase significantly relative to somatic growth. The latter may explain the development of AR.
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Affiliation(s)
- Jürgen Hörer
- Department of Cardiovascular Surgery, German Heart Center Munich at Technical University, Munich, Germany.
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de Kerchove L, Rubay J, Pasquet A, Poncelet A, Ovaert C, Pirotte M, Buche M, D'Hoore W, Noirhomme P, El Khoury G. Ross Operation in the Adult: Long-Term Outcomes After Root Replacement and Inclusion Techniques. Ann Thorac Surg 2009; 87:95-102. [DOI: 10.1016/j.athoracsur.2008.09.031] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 09/10/2008] [Accepted: 09/11/2008] [Indexed: 11/26/2022]
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Elkins RC, Thompson DM, Lane MM, Elkins CC, Peyton MD. Ross operation: 16-year experience. J Thorac Cardiovasc Surg 2008; 136:623-30, 630.e1-5. [PMID: 18805263 DOI: 10.1016/j.jtcvs.2008.02.080] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2005] [Revised: 10/29/2007] [Accepted: 02/25/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We performed a review of a consecutive series of 487 patients undergoing the Ross operation to identify surgical techniques and clinical parameters that affect outcome. METHODS We performed a prospective review of consecutive patients from August 1986 through June 2002 and follow-up through August 2004. Patient age was 2 days to 62 years (median, 24 years), and 197 patients were less than 18 years of age. The Ross operation was performed as a scalloped subcoronary implant in 26 patients, an inclusion cylinder in 54 patients, root replacement in 392 patients, and root-Konno procedure in 15 patients. Clinical follow-up in 96% and echocardiographic evaluation in 77% were performed within 2 years of closure. RESULTS Actuarial survival was 82% +/- 6% at 16 years, and hospital mortality was 3.9%. Freedom from autograft failure (autograft reoperation and valve-related death) was 74% +/- 5%. Male sex and primary diagnosis of aortic insufficiency (no prior aortic stenosis) were significantly associated with autograft failure by means of multivariate analysis. Freedom from autograft valve replacement was 80% +/- 5%. Freedom from endocarditis was 95% +/- 2%. One late thromboembolic episode occurred. Freedom from allograft reoperation or reintervention was 82% +/- 4%. Freedom from all valve-related events was 63% +/- 6%. In children survival was 84% +/- 8%, and freedom from autograft valve failure was 83% +/- 6%. CONCLUSIONS The Ross operation provides excellent survival in adults and children willing to accept a risk of reoperation. Male sex and a primary diagnosis of aortic insufficiency had a negative effect on late results.
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Affiliation(s)
- Ronald C Elkins
- Department of Surgery, Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla 73190, USA.
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A single center's experience with the Ross procedure in pediatrics. Pediatr Cardiol 2008; 29:894-900. [PMID: 18401635 DOI: 10.1007/s00246-008-9224-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 01/18/2008] [Accepted: 03/22/2008] [Indexed: 10/22/2022]
Abstract
The use of a pulmonary autograft for aortic valve replacement (AVR) has become more prevalent than other forms of AVR in the pediatric population. We reviewed the data on pediatric patients who underwent the Ross procedure at our institution from 1993 to 2005. Sixty patients <18 years old who underwent a Ross procedure had available clinical and echocardiographic data collected and statistical analysis performed. Mortality rate was 3.3%, while overall survival and freedom from reoperation of either the homograft or the autograft were 96.7% and 66.2%, respectively, at 10 years. Freedom from reoperation of the left ventricular outflow tract was 60.5% at 10 years. Echocardiographic data showed aortic regurgitation to be mild or less in 76% of patients by last follow-up, while dilation of the sinuses of Valsalva had occurred in 52%. Compared to other AVR options, the Ross procedure in eligible pediatric patients demonstrates good intermediate survival rates and continued growth potential, yet a time-dependent need for reoperation.
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Frigiola A, Ranucci M, Carlucci C, Giamberti A, Abella R, Di Donato M. The Ross Procedure in Adults: Long-Term Follow-Up and Echocardiographic Changes Leading to Pulmonary Autograft Reoperation. Ann Thorac Surg 2008; 86:482-9. [PMID: 18640320 DOI: 10.1016/j.athoracsur.2008.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 03/30/2008] [Accepted: 04/01/2008] [Indexed: 11/18/2022]
Affiliation(s)
- Alessandro Frigiola
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico, Policlinico San Donato, Milan, Italy
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Marino BS, Pasquali SK, Wernovsky G, Pudusseri A, Rychik J, Montenegro L, Shera D, Spray TL, Cohen MS. Accuracy of intraoperative transesophageal echocardiography in the prediction of future neo-aortic valve function after the Ross procedure in children and young adults. CONGENIT HEART DIS 2008; 3:39-46. [PMID: 18373748 DOI: 10.1111/j.1747-0803.2007.00156.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Neo-aortic insufficiency (neo-AI) has been noted following the Ross procedure. The purpose of this study was to evaluate the ability of intraoperative transesophageal echocardiography (TEE) to predict future neo-AI in pediatric patients undergoing the Ross from January 1995 to December 2003, who had an intraoperative TEE, and discharge and follow-up transthoracic (TTE) echocardiograms. DESIGN Retrospective case series. PATIENTS All patients who underwent the Ross procedure at Children's Hospital of Philadephia between January 1995 and December 2003, and had an intraoperative TEE, discharge, and follow-up (>6 months) transthoracic echocardiogram (TTE) (by July 1, 2004) were included. OUTCOME MEASURES Grade of neo-AI was assessed on intraoperative TEE, discharge, and follow-up TTE echocardiogram reports. RESULTS Follow-up was available in 99/115 (86%) survivors. Median age at Ross was 9.3 years (4 days-34 years). No patient had more than mild neo-AI on intraoperative TEE. At discharge, 2 patients (2%) had moderate neo-AI. At most recent follow-up (median 4.2 years, 8 months-9.3 years), 21 patients (21%) had moderate or greater neo-AI; 9 underwent neo-aortic reintervention. The presence of any neo-AI on intraoperative TEE had 100% sensitivity and negative predictive value for diagnosing moderate or greater neo-AI at discharge. Patients who had mild neo-AI on TEE were more likely to have moderate or greater neo-AI at most recent follow-up than those patients with no neo-AI on TEE (9% vs. 30%, P = 0.01). CONCLUSION Intraoperative TEE is an excellent screening tool for the presence of significant neo-AI at the time of hospital discharge. Neo-AI progresses over time after Ross procedure and is more likely to progress in those patients with neo-AI on intraoperative TEE. However, predictive validity decreases over time as neo-AI progresses.
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Affiliation(s)
- Bradley S Marino
- Children's Hospital of Philadelphia, Pediatrics Divisions of Cardiology, Philadelphia, PA, USA.
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Aslam AK, Aslam AF, Vasavada BC, Khan IA. Prosthetic heart valves: Types and echocardiographic evaluation. Int J Cardiol 2007; 122:99-110. [PMID: 17434628 DOI: 10.1016/j.ijcard.2006.12.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Revised: 12/15/2006] [Accepted: 12/30/2006] [Indexed: 11/30/2022]
Abstract
In the last five decades multiple different models of prosthetic valves have been developed. The purpose of this article is to provide a comprehensive source of information for the types and the echocardiographic evaluation of the prosthetic heart valves.
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Affiliation(s)
- Ahmad Kamal Aslam
- Division of Cardiology, Beth Israel Medical Center, 16th Street 1st Avenue, New York, NY 10003, USA.
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Brown JW, Ruzmetov M, Rodefeld MD, Mahomed Y, Turrentine MW. Incidence of and Risk Factors for Pulmonary Autograft Dilation After Ross Aortic Valve Replacement. Ann Thorac Surg 2007; 83:1781-7; discussion 1787-9. [PMID: 17462399 DOI: 10.1016/j.athoracsur.2006.12.066] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 12/22/2006] [Accepted: 12/27/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Ross procedure is an alternative to mechanical aortic valve replacement in the young. Early dilation of the pulmonary autograft root exposed to the systemic circulation has been reported. The aim of our study is to define the prevalence, risk factors, and consequences of autograft dilation. All consecutive adult and pediatric patients who underwent Ross procedure at our institution were retrospectively reviewed for autograft dilation. METHODS Between 1993 and 2005, 170 patients (mean age, 24.9 +/- 15.5 years; range, 1 month to 61 years) underwent Ross aortic valve replacement: 48% were younger than 19 years old. Eighty-seven additional procedures were performed in 58 patients (34%) at the time of the Ross procedure. End points of the study were freedom from autograft dilation (z value more than +2.0), autograft dysfunction, autograft reoperation, and autograft replacement. RESULTS There were 2 early and 1 late deaths during a mean follow-up of 5.1 +/- 3.0 years (range, 1 month to 12 years). Actuarial survival at 10 years was 98%. Autograft dilation was identified in 31 patients (19%). Regurgitation (>2+) was identified in 12 patients (7%); all 12 had autograft dilation. At 10 years, freedom from autograft dilation was 82%, freedom from autograft dysfunction was 92%, freedom from reoperation on autograft was 92%, and freedom from autograft replacement was 96%. Cox proportional hazard analysis identified preoperative aortic annulus dilation (z value more than +2.0; p = 0.004), younger age (p = 0.05), time of surgery (before 2001; p = 0.002), and male sex (p = 0.01) as predictive of autograft dilation, whereas preoperative ascending aorta diameter (p = 0.01), male sex (p = 0.03), and postoperative systemic hypertension (p = 0.05) were predictive of autograft dysfunction. CONCLUSIONS Significant autograft dilation is not common after the Ross procedure. Significant autograft dysfunction affects a minority of patients, but it is more prevalent in those with autograft dilation.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA.
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Pasquali SK, Cohen MS, Shera D, Wernovsky G, Spray TL, Marino BS. The Relationship Between Neo-Aortic Root Dilation, Insufficiency, and Reintervention Following the Ross Procedure in Infants, Children, and Young Adults. J Am Coll Cardiol 2007; 49:1806-12. [PMID: 17466232 DOI: 10.1016/j.jacc.2007.01.071] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Revised: 12/20/2006] [Accepted: 01/09/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The purpose of this study was to describe the relationship between neo-aortic root size, neo-aortic insufficiency (AI), and reintervention at mid-term follow-up. BACKGROUND Data on neo-aortic valve function and growth after the Ross procedure in children are limited. METHODS A total of 74 of 119 Ross patients from January 1995 to December 2003 had > or =2 follow-up echocardiograms at our institution and were included. Neo-aortic dimensions were converted to z-scores and modeled over time. Kaplan-Meier analysis was used to assess freedom from neo-aortic outcomes, and predictors were identified through multivariate analysis. RESULTS Median age at Ross was 9 years (range 3 days to 34 years). Over 4.7 years (range 3 months to 9.3 years) follow-up, there was disproportionate enlargement of the neo-aortic root (z-score increase of 0.75/year [p < 0.0001]). Neo-AI progressed > or =1 grade in 36% of patients and > or =2 grades in 15%. Nine patients (12%) had neo-aortic reintervention at 2.0 years (range 1.1 to 9.5 years) after the Ross procedure owing to severe neo-AI (n = 7), neo-aortic root dilation (n = 1), and neo-aortic pseudoaneurysm (n = 1). At 6 years after the Ross procedure, freedom from neo-aortic reintervention was 88%. Freedom from neo-aortic root z-score >4 was only 3% and from moderate or greater neo-AI was 60%. Longer follow-up time was associated with neo-aortic root dilation (p < 0.0001). Prior ventricular septal defect (VSD) repair predicted neo-AI (p = 0.02) and reintervention (p = 0.03). Prior aortic valve replacement (p = 0.002) also predicted neo-AI. Neo-aortic root dilation was not associated with neo-AI or reintervention. CONCLUSIONS At mid-term follow-up after the Ross procedure, neo-aortic root size increases significantly out of proportion to somatic growth, and neo-AI is progressive. Prior VSD repair and aortic valve replacement were associated with neo-AI and reintervention.
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Affiliation(s)
- Sara K Pasquali
- Division of Cardiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Pasquali SK, Shera D, Wernovsky G, Cohen MS, Tabbutt S, Nicolson S, Spray TL, Marino BS. Midterm outcomes and predictors of reintervention after the Ross procedure in infants, children, and young adults. J Thorac Cardiovasc Surg 2007; 133:893-9. [PMID: 17382622 DOI: 10.1016/j.jtcvs.2006.12.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 10/03/2006] [Accepted: 12/18/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study assessed the type, time course, and risk factors for right and left ventricular outflow tract reinterventions after the Ross procedure in a population of infants, children, and young adults. METHODS Patients who underwent the Ross procedure between January 1995 and June 2004 were included (n = 121 consecutive patients). Kaplan-Meier and hazard analyses of right and left ventricular outflow tract reinterventions were performed, and predictors of reintervention were identified through multivariate analysis. RESULTS The median age at the Ross procedure was 8.2 years (4 days to 34 years); 20% were aged less than 1 year. Half of the patients had isolated aortic valve disease; the other half had complex left-sided heart disease. Early mortality (<30 days) was 2.5% (n = 3). There were 2 late deaths (1.7%). Follow-up (median 6.5 years [2.5 months to 10.4 years]) was available for 96% of survivors (n = 111). Right ventricular outflow tract reintervention (n = 22 in 15 patients) was performed 2.0 years (2.0 weeks to 9.8 years) after the Ross procedure because of stenosis in 19 of 22 cases. Freedom from right ventricular outflow tract reintervention at 8 years was 81%. Smaller homograft size was the strongest predictor (P < .001) of right ventricular outflow tract reintervention. Left ventricular outflow tract reintervention (n = 15 in 15 patients) was performed 2.8 years (1.0 months to 11.6 years) after the Ross procedure because of severe neoaortic insufficiency in 10 of 15 patients. Freedom from left ventricular outflow tract reintervention at 8 years was 83%. Native pulmonary valve abnormalities (P < .01), original diagnosis of aortic insufficiency (P < .01), prior aortic valve replacement (P = .01), and prior ventricular septal defect repair (P = .04) predicted left ventricular outflow tract reintervention. CONCLUSIONS At midterm follow-up after the Ross procedure, interim mortality is rare. Neoaortic insufficiency and right ventricle to pulmonary artery conduit obstruction are common postoperative sequelae, requiring reintervention in one quarter of patients.
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Affiliation(s)
- Sara K Pasquali
- Division of Cardiology in the Departments of Pediatrics, Surgery, and Anesthesia/Critical Care Medicine at The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pa 19104, USA
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Chiappini B, Absil B, Rubay J, Noirhomme P, Funken JC, Verhelst R, Poncelet A, El Khoury G. The Ross Procedure: Clinical and Echocardiographic Follow-Up in 219 Consecutive Patients. Ann Thorac Surg 2007; 83:1285-9. [PMID: 17383328 DOI: 10.1016/j.athoracsur.2006.11.072] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 11/21/2006] [Accepted: 11/21/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The replacement of the diseased aortic valve with a pulmonary autograft has been shown to provide excellent hemodynamic results and to be associated with low morbidity and mortality rates. METHODS From 1991 to 2005, 219 patients undergoing the Ross operation were identified. All patients underwent transthoracic echocardiography at discharge and were scheduled for a yearly study thereafter. The echocardiographic study consisted of a morphologic analysis of the pulmonary autograft with measurement of end-systolic diameters at three levels: annulus, sinuses of Valsalva, and origin of the ascending aorta 2 cm above the sinotubular junction. The dynamic analysis evaluated the function of the aortic autograft and the pulmonary homograft. Maximal and mean aortic and pulmonary transvalvular pressure gradients were investigated. RESULTS The 30-day mortality was 1.8% (n = 4). Cardiac deaths were not related to the autograft. The 10-year actuarial survival was 95.7% +/- 2.1%. Six patients (2.8%) had grade 2 autograft valve regurgitation. No grade 3 or 4 pulmonary regurgitation was identified. At their most recent follow-up, 28 patients (13.1%) had grade 1 insufficiency of the pulmonary homograft, and 10 patients (4.6%) had a peak transvalvular gradient of 17.9 +/- 10.2 mm Hg. CONCLUSIONS Our current experience suggests that replacement of the aortic root with a pulmonary autograft can be safely performed in infants, children, and adults and is associated with low mortality and morbidity rates. It constitutes an elegant alternative to the use of prosthetic valves in the treatment of aortic valve diseases.
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Affiliation(s)
- Bruno Chiappini
- Department of Thoracic and Cardiovascular Surgery, Saint Luc Hospital, Université Catholique de Louvain, Brussels, Belgium.
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Koul B, Al-Rashidi F, Bhat M, Meurling C. A modified Ross operation to prevent pulmonary autograft dilatation. Eur J Cardiothorac Surg 2007; 31:127-8. [PMID: 17092738 DOI: 10.1016/j.ejcts.2006.10.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Revised: 10/02/2006] [Accepted: 10/03/2006] [Indexed: 11/20/2022] Open
Abstract
A modification in Ross operation is described in which the free-standing pulmonary autograft root is suspended in a Dacron prosthetic vascular jacket with a view to prevent dilatation of the neo-aortic root. In a group of 13 patients operated consecutively using this technique, there was no significant increase in the diameters of the neo-aortic root after a mean 16-month follow-up. Aortic valve function remained also satisfactory.
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Affiliation(s)
- Bansi Koul
- Cardiothoracic Surgery, University Hospital Lund, 221 85 Lund, Sweden.
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Brown JW, Ruzmetov M, Vijay P, Rodefeld MD, Turrentine MW. The Ross-Konno Procedure in Children: Outcomes, Autograft and Allograft Function, and Reoperations. Ann Thorac Surg 2006; 82:1301-6. [PMID: 16996923 DOI: 10.1016/j.athoracsur.2006.05.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 04/27/2006] [Accepted: 05/03/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Ross aortic valve replacement with a modified Konno-type enlargement Ross-Konno procedure of the aortic annulus and subannular region allows an autograft aortic valve replacement for children with significant annular and subannular hypoplasia. The potential for growth and the proven durability of the autograft make the Ross-Konno procedure an ideal aortic valve replacement for this subgroup with multilevel left ventricular outflow tract obstruction. We reviewed our institutional midterm experience to assess autograft and homograft hemodynamics, and management after a Ross-Konno procedure. METHODS Between 1995 and 2005, 14 consecutive children (mean age, 6.4 +/- 5.9 years; range, 1 month to 17 years) underwent the Ross-Konno procedure. All children had severe to critical aortic stenosis or multilevel left ventricular outflow tract obstruction. RESULTS There was 1 early and 1 late death with a mean follow-up of 5.7 +/- 3.6 years. Actuarial survival at 10 years was 86%. Three patients underwent right ventricular outflow tract reoperation for conduit replacement for homograft dysfunction and one patient required redo aortic root replacement with a mechanical valves for progressive aortic insufficiency. Freedom from right ventricular outflow tract and autograft reoperation at 10 years is 77% and 92%, respectively. Aortic annular dilation was not observed in all patients. Univariate and multivariate analysis identified no risk factors for autograft or homograft valve-related reoperation. CONCLUSIONS The Ross-Konno procedure is an excellent technique to treat complex multilevel left ventricular outflow tract obstruction in children with significant annular and subannular hypoplasia. The autograft demonstrated durability without development of aortic stenosis or progressive dilation and a low incidence of developing progressive aortic insufficiency. Enlargement of the aortic annulus appear to parallel somatic growth in most instances.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA.
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Abstract
For patients requiring intervention because of progressive disease of the aortic valve, the perfect palliation will provide a valve that produces normal dynamics of flow, will not require anti-coagulation, will grow with the patient, and have long term durability. Current surgical interventions include aortic valvoplasty, or replacement with either a mechanical or tissue prosthesis. Options for tissue valves include insertion of a pulmonary autograft in the Ross procedure, a cadaveric homograft, or porcine or bovine xenograft valves. The optimal option is still debated.
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Affiliation(s)
- Bradley S Marino
- Divisione of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA.
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Williams IA, Quaegebeur JM, Hsu DT, Gersony WM, Bourlon F, Mosca RS, Gersony DR, Solowiejczyk DE. Ross procedure in infants and toddlers followed into childhood. Circulation 2006; 112:I390-5. [PMID: 16159852 DOI: 10.1161/circulationaha.104.524975] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Ross procedure is commonly used to treat aortic valve disease in pediatric and adult patients. For infants, data are limited regarding survival, reintervention, autograft growth, and function. METHODS AND RESULTS The Ross procedure was performed in 27 infants <18 months of age (median age 5.7 months). All patients had congenital aortic stenosis (AS); associated lesions included subAS (n=9), supravalvular AS (n=2), coarctation (n=5), and interrupted aortic arch (n=2). Median follow-up was 6.1 years (range 0.2 to 12.9). There were 3 early deaths and no late deaths. Freedom from reintervention for homograft dysfunction was 87% at 8 years; freedom from autograft reintervention was 100%. Follow-up echocardiograms were available in 17 patients. Estimated peak autograft gradient was 55 mm Hg in one patient and <10 mm Hg in 16. Mild autograft insufficiency was seen in 4 patients; 13 had none. Autograft diameter was measured early postoperatively and at latest follow-up. The mean z score increased from 0.63 to 3.2 (P<0.01) at the annulus and from 0.26 to 2.2 (P<0.01) at the sinus. In a subgroup, the mean autograft z score increased significantly from the postoperative period to 1 year for both the annulus (0.72 to 3.2, P<0.01) and the sinus (0.26 to 2.2, P<0.01), but remained unchanged thereafter. CONCLUSIONS The Ross procedure effectively relieves AS in infants. Homograft reintervention occurred in 13% within 8 years. No patient developed significant autograft insufficiency or required autograft reintervention during the follow-up period. Dilatation of the autograft occurred during the first year after surgery and stabilized thereafter.
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Affiliation(s)
- Ismee A Williams
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York, New York, NY 10032, USA.
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Slater M, Shen I, Welke K, Komanapalli C, Ungerleider R. Modification to the Ross procedure to prevent autograft dilatation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:181-4. [PMID: 15818376 DOI: 10.1053/j.pcsu.2005.01.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Dilatation of the pulmonary autograft is a problem described following Ross procedure for aortic valve replacement. Patients at risk seem to be those with aortic insufficiency, bicuspid aortic valves, and those with aneurismal ascending aortas. We describe a technique for encasing the pulmonary autograft in a Dacron tube to prevent dilatation in these patients. This technique is reproducible and includes sewing the coronary arteries to all layers of the autograft and Dacron construct. Short-term follow-up shows excellent outcomes with respect to autograft valve function and lack of annular or sinotubular dilatation. This procedure may be useful for extending the Ross procedure to young adults, where autograft growth is no longer needed, to provide a non-dilatable neoaortic root.
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Affiliation(s)
- Matthew Slater
- Department of Pediatric Cardia Surgery, Doernbecher Children's Hospital, Portland, OR 97239, USA
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Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Dávila-Román VG. The Ross procedure: Long-term clinical and echocardiographic follow-up. Ann Thorac Surg 2004; 78:773-81; discussion 773-81. [PMID: 15336990 DOI: 10.1016/j.athoracsur.2004.02.033] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2004] [Indexed: 11/15/2022]
Abstract
BACKGROUND Progressive dilatation of the pulmonary autograft is the principal cause for reoperation following the Ross procedure when the root replacement technique is used. We examined the relation between enlargement of the pulmonary autograft and the development and progression of neo-aortic valve regurgitation, and the long-term clinical follow-up, including the need for reoperation, in patients followed for up to 13 years postoperatively. METHODS A Ross procedure was performed on 119 older children and young adults (mean age: 31 years old), using the root replacement technique, between June 1989 and January 2002. Serial echocardiography studies were obtained in 108 patients and analyzed blinded to clinical data. The following variables were measured: diameter of annulus, sinuses of Valsalva, and supravalvular ridge; presence and severity of aortic regurgitation; and valve thickening. RESULTS The 30 day and late mortality rates were 1.7% and 1.7% (2 patients each). Forty-one patients were followed for more than 5 years, 19 for more than 7 years, and 9 for more than 10 years. There was one thrombotic and no endocarditis events. The 10-year actuarial survival was 96%. Reoperation on the pulmonary autograft or the pulmonary allograft was required in 12 patients. The principal indication for operation on the pulmonary autograft in 11 patients was neo-aortic valve regurgitation (7), aneurysm formation (3), and false aneurysm (1). At 10 years, actuarial freedom from reoperation on the pulmonary autograft was 75%. At last follow-up, 8 of 97 patients without reoperation on the autograft had moderate and none had severe regurgitation of the neo-aortic valve. Independent predictors of progression of neo-aortic valve regurgitation were time from operation, dilatation of the supravalvular ridge, and neo-aortic valve thickening (all p < 0.0002). Freedom from reoperation in the pulmonary allograft at 10 years was 86%. CONCLUSIONS Long-term follow-up of patients with the Ross procedure using the root replacement technique indicates excellent survival and low thromboembolic and endocarditis risk. The main limitation is the need for reoperation. The prevalence of severe neo-aortic valve regurgitation is low, however there is a progressive increase in regurgitation and in aortic root diameters. Periodic follow-up with echocardiography is recommended because of the continuing risk of progressive regurgitation of the neo-aortic valve and aneurysm formation.
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Affiliation(s)
- Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, Missouri, USA.
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McMahon CJ, Ravekes WJ, Smith EO, Denfield SW, Pignatelli RH, Altman CA, Ayres NA. Risk factors for neo-aortic root enlargement and aortic regurgitation following arterial switch operation. Pediatr Cardiol 2004; 25:329-35. [PMID: 14727099 DOI: 10.1007/s00246-003-0483-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The objectives of this study were to evaluate changes in dimension of the neo-aortic annulus, aortic root, and aortic anastomosis following arterial switch operation (ASO) and to identify risk factors for developing abnormal neo-aortic root enlargement and aortic regurgitation (AR). Prior studies report development of neo-aortic root dilatation and AR in a small subset of patients after ASO. Predisposing factors for neo-aortic root dilatation and development of moderate/severe AR are poorly understood. We performed a retrospective review of all patients with d-transposition of the great arteries (d-TGA) or double-outlet right ventricle with subpulmonary ventricular septal defect (VSD) who underwent ASO from May 1986 to January 2001. Serial echocardiograms were reviewed to measure neo-aortic annulus, root, and anastomosis diameter (z scores) and to determine progression of AR. Potential risk factors were assessed for developing neo-aortic root enlargement and AR. There were 119 patients (44 female and 75 male): 73 patients had simple d-TGA, 36 had d-TGA with ventricular septal defect, and 10 had a Taussig-Bing heart. The median duration of follow-up was 65 months (range, 12-180). The median neo-aortic root (z = 0.55+/-2.2; p < 0.01) and aortic annulus dimensions (z = 1.57+/-1.75; p < 0.01) were significantly increased over the study period. Aortic anastomosis diameter correlated with growth of the ascending aorta (z = 0.55+/-1.24). Development of severe neo-aortic root enlargement was associated with prior pulmonary artery (PA) banding (p < 0.01), the presence of a VSD (p = 0.03), and Taussig-Bing anatomy (p < 0.01) but was independent of coronary arterial anatomy, coronary arterial transfer technique, or associated lesions (p > 0.05). At latest follow-up, there was no or trivial AR in 88 patients, mild AR in 29 patients, and moderate to severe AR in 3 patients. Risk factors for developing mild or worse AR included severe or rapid neo-aortic root dilatation (p < 0.01). Only 3 patients required surgical intervention for AR. Despite the significant prevalence of neo-aortic root enlargement at intermediate follow-up after ASO, there is a low incidence of significant AR. Prior PA banding, the presence of VSD, and Taussig-Bing anatomy are risk factors for severe root enlargement. Surgical intervention for AR was rare (2%), however, serial surveillance of such patients is vital to monitor for neo-aortic root enlargement and potential aortic valve dysfunction.
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Affiliation(s)
- C J McMahon
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA.
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Villavicencio RE, Humes RA, Epstein ML, Walters HL, Hakimi M, Thomas RL, Tantengco MVT. Abrupt aortic root dilation after the Ross procedure--is this a progressive phenomenon? J Card Surg 2003; 18:384-9. [PMID: 12974922 DOI: 10.1046/j.1540-8191.2003.02045.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study provides evidence of aortic root dilation in children, adolescents, and young adults who have undergone the Ross procedure. Several mechanisms are described.
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Affiliation(s)
- Rafael E Villavicencio
- Department of Pediatrics, Division of Cardiology, Wayne State University School of Medicine, Detroit, MI, USA
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Masetti P, Davila-Roman VA, Kouchoukos NT. Valve-sparing procedure for dilatation of the autologous pulmonary artery and ascending aorta after the Ross operation. Ann Thorac Surg 2003; 76:915-6. [PMID: 12963228 DOI: 10.1016/s0003-4975(03)00196-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The need for reoperation remains a principal limitation of the Ross procedure and most commonly includes replacement of the neo-aortic valve. We describe the use of a valve-sparing procedure in a patient with progressive dilatation of the pulmonary autograft and the remaining native ascending aorta and mild regurgitation of the neo-aortic valve.
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Affiliation(s)
- Paolo Masetti
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St Louis, Missouri 63131, USA
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Cohen MS, Marino BS, McElhinney DB, Robbers-Visser D, van der Woerd W, Gaynor JW, Spray TL, Wernovsky G. Neo-aortic root dilation and valve regurgitation up to 21 years after staged reconstruction for hypoplastic left heart syndrome. J Am Coll Cardiol 2003; 42:533-40. [PMID: 12906985 DOI: 10.1016/s0735-1097(03)00715-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We sought to assess the prevalence and progression of neo-aortic root dilation and valvar regurgitation after staged reconstruction for hypoplastic left heart syndrome (HLHS). BACKGROUND In HLHS, the pulmonary valve functions as the neo-aortic valve. Neo-aortic valve dysfunction has been observed after arterial switch operation and the Ross procedure. METHODS Patients with HLHS born before January 1995 who had the Fontan operation and had serial echocardiograms were included. Echocardiograms were reviewed preoperatively, after each surgical reconstruction, and at most recent follow-up for neo-aortic root size and severity of neo-aortic regurgitation (AR). Potential risk factors for neo-aortic valve dysfunction were assessed. RESULTS Fifty-three patients met inclusion criteria. Bidirectional superior cavopulmonary anastomosis as an interim procedure was performed in 39 patients (74%). Median duration of follow-up was 9.2 (range 5.1 to 21) years. During follow-up, the neo-aortic root progressively dilated out of proportion to body size over time, with 52 patients (98%) having a Z-score >2 at most recent follow-up. Neo-AR was present in 61% of patients at most recent follow-up, with progression over time in 26 patients (49%). However, neo-AR was more than mild in only three patients. Significantly larger neo-aortic root Z-scores were observed in patients with any degree of neo-AR at most recent follow-up. No other anatomic or clinical variables correlated with severity of neo-AR or root dilation. CONCLUSIONS After staged reconstruction for HLHS, neo-aortic root dilation and neo-AR progress over time. Early volume unloading does not have a beneficial impact on dilation of the neo-aortic root. These findings raise concerns about neo-aortic valve function into adulthood.
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Affiliation(s)
- Meryl S Cohen
- Department of Pediatrics, University of Pennsylvania School of Medicine, Cardiac Center at Children's Hospital of Philadelphia, 19104, USA.
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Ishizaka T, Devaney EJ, Ramsburgh SR, Suzuki T, Ohye RG, Bove EL. Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure. Ann Thorac Surg 2003; 75:1518-22. [PMID: 12735572 DOI: 10.1016/s0003-4975(02)04904-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Aortic insufficiency secondary to progressive dilatation of the pulmonary autograft is being recognized with increasing frequency after the Ross procedure. We reviewed our experience with valve-sparing aortic root replacement concomitant with aortic annuloplasty to assess the effectiveness of this approach. METHODS Four patients, aged 8 to 27 years, presented with moderate to severe aortic insufficiency associated with progressive root dilatation from 1 to 8 years after a Ross procedure. All patients had 0 to 1+ aortic insufficiency early after the Ross procedure, with a mean maximal sinus diameter of 37 mm (range 30 to 45 mm). At reoperation the maximum diameter of the root ranged from 45 to 55 mm (mean 50 +/- 4 mm). A valve-sparing aortic root replacement with annular reduction was performed. The annulus was decreased from a mean of 27 mm to 23 mm. For the root replacement, 1 patient underwent a standard root remodeling procedure; in the others, a separate piece of scalloped Dacron (C.R. Bard, Haverhill, PA) graft material was used for each sinus to facilitate optimal exposure. RESULTS All 4 patients are in New York Heart Association functional class I at a mean follow-up of 6 months. The most recent echocardiography demonstrated 0 to 1+ aortic insufficiency with good left ventricular function. Histology of the excised pulmonary autograft walls demonstrated severe elastin fragmentation. CONCLUSIONS Aortic root remodeling with annular reduction is an effective treatment for aortic root dilatation and aortic insufficiency after the Ross operation. This procedure allows correction of aortic insufficiency and avoids the need for a prosthetic valve and anticoagulation.
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Affiliation(s)
- Toru Ishizaka
- Division of Pediatric Cardiovascular Surgery, Section of Cardiac Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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Koul B, Lindholm CJ, Koul M, Roijer A. Ross operation for bicuspid aortic valve disease in adults: is it a valid surgical option? SCAND CARDIOVASC J 2002; 36:48-52. [PMID: 12018767 DOI: 10.1080/140174302317282384] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE The validity of the Ross operation as freestanding root replacement in adult patients with bicuspid aortic valve disease has lately been questioned. We have analyzed retrospectively our results in 23 adult patients (19 males) operated for bicuspid aortic valve disease ad modum "Ross" employing a freestanding root replacement technique. DESIGN In 9 patients the dominant aortic valve lesion was stenotic (aortic stenosis group) and in the remaining 14 patients it was aortic insufficiency (aortic insufficiency group). The fate of the pulmonary autograft in the two groups was studied. The intraoperatively measured aortic and pulmonary annuli diameters from the two groups were compared with those from a population of normal looking aortic and pulmonary valves matched for body surface area. RESULTS The aortic insufficiency group needed significant reduction of the aortic annulus diameter to conform to the size of the pulmonary autograft. The pulmonary autograft annuli in this group were significantly larger in diameter than the ones in the aortic stenosis group. The mean pulmonary annulus diameter in the aortic stenosis group was, on the other hand, significantly smaller when compared with that in the normal matched population. After a mean follow-up period of about 19 months, the aortic insufficiency group showed significant dilatation of the neo-aortic sinuses. Between the two groups, the remaining echocardiographic variables remained either stable or improved at follow-up. CONCLUSION Pre-existing larger diameters of the aortic and pulmonary annuli in the aortic insufficiency group combined with the significantly increased left ventricular end-diastolic diameters, may predispose these patients to significant dilatation of the unsupported aortic sinuses after a Ross operation. This dilatation does not, however, lead to increase in the autograft valve insufficiency at short-term follow-up if the aortic annulus and the distal ascending aorta are tailored to the size of the pulmonary autograft. Ross operation, employing freestanding aortic root replacement technique, may therefore be recommended in adult patients with bicuspid aortic valve disease with excellent short-term results.
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Affiliation(s)
- Bansi Koul
- Speciality of Cardiothoracic Surgery, Heart and Lung Division, University Hospital, Lund, Sweden.
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Ohye RG, Gomez CA, Ohye BJ, Goldberg CS, Bove EL. The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function. Ann Thorac Surg 2001; 72:823-30. [PMID: 11565665 DOI: 10.1016/s0003-4975(01)02814-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Ross procedure has been increasingly applied to neonates and infants. Addition of a modified Konno-type enlargement of the aortic annulus allows the application of this procedure to neonates and infants with significant annular hypoplasia. The potential for growth and the proven durability make the autograft an ideal aortic valve replacement. METHODS Between March 1993 and December 2000, 10 patients under 1 year of age underwent a Ross/Konno procedure at our institution (range, 2 to 349 days; median 16). All patients had severe to critical aortic stenosis. All patients required aortic annulus enlargement for size mismatch between the aortic and pulmonary valves. RESULTS There were no deaths at a median follow-up of 48 months (range, 1 to 74 months). All patients had none to mild aortic stenosis on Doppler echocardiography. Eight patients had a 0 to 1+ aortic insufficiency, 1 patient had a 2+ aortic insufficiency, and 1 patient had a 3+ aortic insufficiency. Aortic annular dilatation was not observed. Aortic sinus dilatation occurred initially (mean change in z-value: 0 to 12 months, +2.1) and then stabilized (mean change in z-value: 12 to > 36 months, +0.6). No patient required additional procedures for aortic valve disease. Two patients required three pulmonary allograft replacements. CONCLUSIONS The Ross procedure with a modified Konno-type enlargement of the aortic annulus is an excellent approach to aortic valve disease in the neonate and infant. The procedure can be accomplished with low morbidity and mortality, and low rates of reoperation. The pulmonary autograft demonstrates durability without developing aortic stenosis, aortic insufficiency, or progressive dilatation. Enlargement of the aortic annulus parallels somatic growth.
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Affiliation(s)
- R G Ohye
- Division of Pediatric Cardiovascular Surgery, University of Michigan School of Medicine, Ann Arbor 48109, USA.
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Solowiejczyk DE, Bourlon F, Apfel HD, Hordof AJ, Hsu DT, Crabtree G, Galantowicz M, Gersony WM, Quaegebeur JM. Serial echocardiographic measurements of the pulmonary autograft in the aortic valve position after the Ross operation in a pediatric population using normal pulmonary artery dimensions as the reference standard. Am J Cardiol 2000; 85:1119-23. [PMID: 10781763 DOI: 10.1016/s0002-9149(00)00707-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Serial echocardiographic measurements of the annulus and sinus were obtained in children before the Ross operation, and early and late postoperatively. Values were compared with normal standards for the aorta and pulmonary artery (PA). There was no significant difference between PA annulus measurements before surgery and the corresponding autograft immediately afterward (1.73 +/- 0.60 cm preoperatively; 1. 63 +/- 0.58 cm postoperatively, p = NS). Late after surgery the mean annulus diameter was enlarged compared with the normal aorta (DeltaZ 1.9 +/- 2.4), but remained relatively unchanged compared with the normal PA (DeltaZ 0.7 +/- 1.1, p <0.01). In contrast, the autograft sinus was dilated early after surgery (1.83 +/- 0.58 cm preoperatively; 2.18 +/- 0.73 cm postoperatively, p <0.01). Mean sinus Z score further increased compared with both the aorta (DeltaZ 1.3 +/- 1.7) and PA (DeltaZ 1.3 +/- 1.6). Use of standard PA measurements may be important in the assessment of autograft enlargement. Minimal change in autograft Z scores over time suggests that annulus enlargement is mainly due to somatic growth. In contrast, the autograft sinus showed an immediate and continued disproportionate increase in size over time, suggesting that sinus enlargement is largely due to passive dilation.
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Affiliation(s)
- D E Solowiejczyk
- Divison of Pediatric Cardiology, Columbia University, New York, NY 10032, USA.
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Savoye C, Auffray JL, Hubert E, Godart F, Francart C, Goullard L, Deklunder G, Rey C, Prat A. Echocardiographic follow-up after Ross procedure in 100 patients. Am J Cardiol 2000; 85:854-7. [PMID: 10758926 DOI: 10.1016/s0002-9149(99)00880-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The Ross procedure could provide an ideal aortic valve replacement method in children and young adults. We evaluated midterm echocardiographic results to assess pulmonary homograft function as well as pulmonary autograft dimensions and function. In all, 105 patients (26 women and 79 men) underwent the Ross procedure; median age at implant was 29 years. All patients underwent free root replacement. Transvalvular gradients and autograft dimensions were measured at 3 levels (annulus, sinuses of Valsalva, and proximal aorta) at discharge, at 6 months, and annually thereafter. Perioperative mortality was 4.7%. The mean period for echocardiographic follow-up in 100 patients was 32.7 months (range 0.5 to 7 years), during which 4 noncardiac-related deaths occurred. Two patients underwent late reintervention. No moderate or severe regurgitation was recorded. There was 1 case of mild homograft regurgitation and 4 of mild autograft regurgitation at late follow-up. Autograft peak gradients were low and reproducible (5 +/- 2.8 mm Hg at discharge vs 5.5 +/- 3.5 mm Hg at last follow-up, p = NS). Homograft peak gradients increased significantly without severe obstruction (7.8 +/- 5.7 mm Hg at discharge vs 15.8 +/- 9.2 mm Hg at last follow-up). The diameter of the autograft annulus was stable during follow-up, whereas autograft dimensions at sinuses and proximal aorta increased significantly. One group of patients was identified with sinus diameter increases >20% (group A). The 90 remaining patients were classified into group B. The only parameter significantly different between the 2 groups was the sinus diameters measured at discharge (1.74 cm/m2 (group A) vs 1.92 cm/m2 (group B); p = 0.036). In 100 patients and with echocardiographic follow-up for up to 7 years, the Ross procedure showed excellent results. For 10% of patients, we observed a 20% dilation of sinus diameters, but in only 3 patients (3%) was this beyond the upper normal limit.
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Affiliation(s)
- C Savoye
- Department of Echocardiography, Cardiologic Hospital, Lille, France
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Grunkemeier GL, Li HH, Naftel DC, Starr A, Rahimtoola SH. Long-term performance of heart valve prostheses. Curr Probl Cardiol 2000; 25:73-154. [PMID: 10709140 DOI: 10.1053/cd.2000.v25.a103682] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- G L Grunkemeier
- Medical Data Research Center, Providence Health System, Portland, Oregon, USA
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Abstract
Aneurysm and dissection are the most common diseases affecting the ascending aorta. Graft replacement of the ascending aorta is a straightforward cardiovascular procedure with excellent early and late results. When aneurysm or dissection extends into the aortic sinuses or arch, management becomes more complex and may entail replacement of the aortic root, aortic valve, or a portion of the aortic arch using hypothermic circulatory arrest. The optimal root prosthesis depends on several patient- and procedure-related variables. Valve-sparing procedures confer many long-term advantages and should be considered in all cases where the aortic valve leaflets are normal. The Ross procedure, although ideally suited for isolated aortic valve disease in young patients, may be applicable to some patients with combined aortic valve and ascending aortic disease, unless there is evidence of a systemic connective tissue disorder.
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Affiliation(s)
- D E Cameron
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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