Geometric mismatch of the aortic and pulmonary roots causes aortic insufficiency after the Ross procedure

Long-term autograft dilation and durability after the Ross procedure are similar in infants, children, and adolescents with primary aortic stenosis

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.

Dissemination and implementation analysis of the Ross procedure in adults: time to update the guidelines?

Background

The science of dissemination and implementation (D&I) aims to improve the quality and effectiveness of care by addressing the challenges of incorporating research and evidence-based practice into routine clinical practice. This lens of D&I has challenged the interpretation and incorporation of data, noting that failure of a given therapy may not reflect lack of efficacy, but instead reflect an imperfect implementation. The aim of this manuscript is to review the influence of the Ross procedure's historical context on its D&I.

Methods

A contextual baseline of the Ross procedure was defined from the procedure's original description in the literature to major publications since the 2017 valvular heart disease guidelines. D&I evaluation was conducted using the Consolidated Framework for Implementation Research (CFIR), using constructs from each of the five respective domains to define the main determinants.

Results

Each of the five CFIR domains appears to be correlated with a factor influencing the Ross procedure's varied history of enthusiasm and acceptance. The complex nature of Ross required adaptation for optimization, with a strong correlation of center volume on outcomes that were not considered in non-contemporary studies. Outcomes later published from those studies influenced social and cultural contexts within the aortic surgery community, and led to further organizational uncertainty, resulting in slow guideline incorporation.

Conclusions

The D&I of the Ross procedure was a result of inadequate appreciation of technical complexity, effect of patient selection, and complex aortic surgery experience, resulting in dismissal of an efficacious procedure due to a misunderstanding of effectiveness.

Improved Outcomes Following the Ross Procedure Compared With Bioprosthetic Aortic Valve Replacement

BACKGROUND

The ideal aortic valve substitute for young and middle-aged adults remains elusive.

OBJECTIVES

This study sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving bioprosthetic aortic valve replacements (AVRs).

METHODS

Consecutive patients aged 16-60 years who underwent a Ross procedure or surgical bioprosthetic AVR at the Toronto General Hospital between 1990 and 2014 were identified. Propensity score matching was used to account for differences in baseline characteristics. The primary outcome was all-cause mortality. Secondary outcomes included valve reintervention, valve deterioration, endocarditis, thromboembolic events, and permanent pacemaker implantation.

RESULTS

Propensity score matching yielded 108 pairs of patients. The median age was 41 years (IQR: 34-47 years). Baseline characteristics were similar between the matched groups. There was no operative mortality in either group. Mean follow-up was 14.5 ± 7.2 years. All-cause mortality was lower following the Ross procedure (HR: 0.35; 95% CI: 0.14-0.90; P = 0.028). Using death as a competing risk, the Ross procedure was associated with lower rates of reintervention (HR: 0.21; 95% CI: 0.10-0.41; P < 0.001), valve deterioration (HR: 0.25; 95% CI: 0.14-0.45; P < 0.001), thromboembolic events (HR: 0.15; 95% CI: 0.05-0.50; P = 0.002), and permanent pacemaker implantation (HR: 0.22; 95% CI: 0.07-0.64; P = 0.006).

CONCLUSIONS

In this propensity-matched study, the Ross procedure was associated with better long-term survival and freedom from adverse valve-related events compared with bioprosthetic AVR. In specialized centers with sufficient expertise, the Ross procedure should be considered the primary option for young and middle-aged adults undergoing AVR.

The effectiveness and safety of pulmonary autograft as living tissue in Ross procedure: a systematic review

BACKGROUND

Reports on effectiveness and safety after the implant of pulmonary autograft (PA) living tissue in Ross procedure, to treat both congenital and acquired disease of the aortic valve and left ventricular outflow tract (LVOT), show variable durability results. We undertake a quantitative systematic review of evidence on outcome after the Ross procedure with the aim to improve insight into outcome and potential determinants.

METHODS

A systematic search of reports published from October 1979 to January 2021 was conducted (PubMed, Ovid Medline, Ovid Embase and Cochrane library) reporting outcomes after the Ross procedure in patients with diseased aortic valve with or without LVOT. Inclusion criteria were observational studies reporting on mortality and/or morbidity after autograft aortic valve or root replacement, completeness of follow-up >90%, and study size n≥30. Forty articles meeting the inclusion criteria were allocated to two categories: pediatric patient series and young adult patient series. Results were tabulated for a clearer presentation.

RESULTS

A total of 342 studies were evaluated of which forty studies were included in the final analysis as per the eligibility criteria. A total of 8,468 patients were included (7,796 in pediatric cohort and young adult series and 672 in pediatric series). Late mortality rates were remarkably low alongside similar age-matched mortality with the general population in young adults. There were differences in implantation techniques as regard the variability in stress and the somatic growth that recorded conflicting outcomes regarding the miniroot vs the subcoronary approach.

DISCUSSION

The adaptability of lung autograft to allow for both stress variability and somatic growth make it an ideal conduit for Ross's operation. The use of the miniroot technique over subcoronary implantation for better adaptability to withstand varying degrees of stress is perhaps more applicable to different patient subgroups.

Ross Operation with Autologous External Autograft Stabilization - Long-term Results

BACKGROUND

We have proposed an external stabilization technique to minimize autograft dilatation after the Ross operation. The aim of this study was to analyze autograft function and root dimensions following root replacement with and without external root support.

METHODS

Between 10/1995 and 02/2021, 185 adult patients (73% male; age 38±9 years) underwent a Ross operation as full-root replacement with (n=136) or without support (n=49). Autograft function and root dimensions were determined echocardiographically. Median follow-up was 3.4[1.13-14.74] years; it was 95% complete. Survival and freedom from reoperation were calculated; changes in autograft root dimensions were analyzed using mixed-effect models.

RESULTS

Survival (95%) and freedom from autograft reoperation (94%) at 15 years were higher with than without support (p=0.003 or p=0.004). In the first five years, patients with support showed an indexed root size progression of 0.712mm/(year*m)(p=0.003) compared to 1.554mm/(year*m)(p=0.001) without. Progression rates were higher for patients without stabilization (p=0.045). After five years, progression rates were similar in both groups (0.248mm/(year*m)(p<0.001) with persistent difference between the groups.

CONCLUSIONS

The Ross procedure as full-root replacement is associated with a relevant rate of autograft dilatation and reoperation. The use of external root stabilization may reduce autograft dilatation and is associated with improved survival and durability.

The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques

The Ross procedure is the best operation to treat aortic stenosis (AS) in young and middle-aged adults. However, its role in non-repairable aortic regurgitation (AR) remains debated since many historical series have reported an increased risk of pulmonary autograft dilatation and subsequent need for reintervention in these patients. Some have attributed these findings to an unrecognized and poorly characterized inherited genetic defect that prevents adaptive remodelling of the pulmonary autograft. Herein, we review the contemporary evidence surrounding the use of the Ross procedure in young adults with AR and put forth the argument that with proper technical refinements, the Ross procedure may still be the best operation to treat these patients. We believe that by tailoring the operation to the patient's anatomy and ensuring strict postoperative blood pressure control, one can achieve excellent results with the Ross procedure, including in this challenging patient population.

The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer

The Ross procedure has long been seen as an optimal operation for a select few. The detractors of it highlight the issue of an additional harvesting of the pulmonary artery, subjecting the native PA to systemic pressures and the need for reintervention as reasons to avoid it. However, the PA is a living tissue and capable of adapting and remodeling to growth. We therefore review the current evidence available to discuss the indications, contraindications, harvesting techniques, and modifications in a state-of-the-art narrative review of the PA as an aortic conduit. Due to the lack of substantial well-designed randomized controlled trials (RCTs), we also highlight the areas of need to reiterate the importance of the Ross procedure as part of the surgical armamentarium.

Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study

BACKGROUND

The ideal aortic valve substitute in young and middle-aged adults remains unknown. We sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving a mechanical aortic valve replacement (AVR).

METHODS

From 1990 to 2014, 258 patients underwent a Ross procedure and 1444 had a mechanical AVR at a single institution. Patients were matched into 208 pairs through the use of a propensity score. Mean age was 37.2±10.2 years, and 63% were male. Mean follow-up was 14.2±6.5 years.

RESULTS

Overall survival was equivalent (Ross versus AVR: hazard ratio, 0.91, 95% confidence interval, 0.38-2.16; P=0.83), although freedom from cardiac- and valve-related mortality was improved in the Ross group (Ross versus AVR: hazard ratio, 0.22; 95% confidence interval, 0.034-0.86; P=0.03). Freedom from reintervention was equivalent after both procedures (Ross versus AVR: hazard ratio, 1.86; 95% confidence interval, 0.76-4.94; P=0.18). Long-term freedom from stroke or major bleeding was superior after the Ross procedure (Ross versus AVR: hazard ratio, 0.09; 95% confidence interval, 0.02-0.31; P<0.001).

CONCLUSIONS

Long-term survival and freedom from reintervention were comparable between the Ross procedure and mechanical AVR. However, the Ross procedure was associated with improved freedom from cardiac- and valve-related mortality and a significant reduction in the incidence of stroke and major bleeding. In specialized centers, the Ross procedure represents an excellent option and should be considered for young and middle-aged adults undergoing AVR.

Early and Midterm Results with the Ross Procedure: A Study of the First 31 Cases

Between 1994 and 2002, 31 patients underwent the Ross procedure by a single surgeon. The mean age was 42 years (24–61), 87% were male and 61% were in New York Heart Association (NYHA) class III–IV. Pure aortic stenosis (AS) was present in 32% of patients, pure aortic regurgitation (AR) in 22% and mixed disease in the rest. The aortic valve was bicuspid in 93.5% of the patients. Autograft implantation was by full root replacement in all cases. Concomitant cardiac surgical procedures were carried out in 10/31 (32%). All patients had at least annual clinical and echocardiographic follow-ups. There was one early death (3%). Overall patient survival was 92.7% at 1 year and 86.1% at 5 years. Twenty-eight (96.55%) were in NYHA class I. Echocardiographic follow-up revealed none to trivial AR in 24/29 (82.75%) and mild AR in 4/29 (13.7%). There was no autograft re-operation before 5 years. The mean gradient across the autograft was low (< 4 mm Hg). There were no incidences of endocarditis or thromboembolism. None of the patients required anticoagulation. Our early experience with the Ross procedure has shown good results in relation to early and midterm morbidity, mortality, autograft, and homograft function.

Current readings: Aortic valve-sparing operations

It has been more than 2 decades since aortic valve-sparing operations were introduced to preserve the aortic valve in patients with aortic root aneurysm. Remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, mostly because it preserves the aortic annulus movement during the cardiac cycle. However, several comparative studies have shown that reimplantation of the aortic valve has provided more stable aortic valve function than remodeling of the aortic root. This difference in outcomes is largely because of patients׳ selection. Remodeling of the aortic root has been associated with high failure rates in patients with aneurysms associated with genetic syndromes and bicuspid aortic valves with dilated aortic annulus, but it has provided excellent long-term results in older patients with aortic root aneurysms secondary to ascending aortic aneurysms and normal aortic annulus. Thus, both techniques are useful in preserving the aortic valve. With either technique, restoration of normal aortic annulus and cusp geometry is the single most important technical aspect of these operations. In addition to having a competent valve with no or trivial aortic insufficiency at the end of the operation, there must be no cusp prolapse and the coaptation level of the cusps has to be well above the level of the nadir of the aortic annulus.

The Ross procedure using autologous support of the pulmonary autograft: techniques and late results

OBJECTIVES

It is hypothesized that by performing radical aortic root manipulation and then autologous support for the pulmonary autograft in the Ross procedure, this will maintain aortic root size and should, in turn, lead to the demonstrated low incidence of late aortic regurgitation and need for reoperation on the aortic root and valve.

METHODS

Aortic root size was measured echocardiographically both preoperatively and then at second yearly intervals in 322 consecutive patients who underwent a Ross operation between October 1992 and June 2013 with autologous support of the pulmonary autograft root using the patient's own aorta. This technique, a variant of the inclusion cylinder method, has been developed with the aim of minimizing prosthetic materials in the aortic root.

RESULTS

Measures to reduce aortic root size included annulus reduction in 201 patients (62.4%) and reduction in aortic sinus or sinotubular junction in 159 patients (49.4%). Maximal aortic root diameter postoperatively at 5, 10, and 15 years was 34.0, 34.6, and 34.7 mm, respectively. Eleven reoperations were required during the study period for progressive aortic regurgitation (none for aortic root enlargement), with freedom from reoperation being 96% at both 15 years and 18 years. Preoperative pure aortic regurgitation, aortic annulus, and sinotubular junction enlargement were risk factors for reoperation.

CONCLUSIONS

This inclusion method of pulmonary autograft implantation leads to minimal increases in aortic root size over time, with no reoperations for aortic root dilatation and a low requirement for aortic valve reoperation. The Ross procedure deserves to remain on the surgical menu for aortic valve replacement.

Fluid-structure interaction simulation of aortic valve closure with various sinotubular junction and sinus diameters

This study was designed to investigate the effect of sinotubular junction and sinus diameters on aortic valve closure to prevent the regurgitation of blood from the aorta into the left ventricle during ventricular diastole. The 2-dimensional geometry of a base aortic valve was reconstructed using the geometric constraints and modeling dimensions suggested by literature as the reference model A (aortic annulus diameter (DAA) = 26, diameters of sinotubular junction (DSTJ) = 26, sinus diameter (DS) = 40), and then the DSTJ and DS were modified to create five geometric models named as B (DSTJ = 31.2, DS = 40), C (DSTJ = 20.8, DS = 40), D (DSTJ = 26, DS = 48), E (DSTJ = 26, DS = 32) and F (DSTJ = 31.2, DS = 48) with different dimensions. Fluid structure interaction method was employed to simulate the movement and mechanics of aortic root. The performance of the aortic root was quantified in terms of blood flow velocity through aortic valve, annulus diameter as well as leaflet contact pressure. For comparison among A, B and C, the differences of annulus diameter and leaflet contact pressure do not exceed 5% with DSTJ increased by 1.2 times and decreased by 0.8 times. For comparison among A, D and E, annulus diameter was increased by 6.92% and decreased by 7.87%, and leaflet contact pressure was increased by 8.99% and decreased by 12.14% with DS increased by 1.2 times and decreased by 0.8 times. For comparison between A and F, annulus diameter was increased by 5.10%, and leaflet contact pressure was increased by 13.54% both with DSTJ and DS increased by 1.1 times. The results of leaflet contact pressure presented for all models were consistent with those of aortic annulus diameters. For the Ross operation involves replacing the diseased aortic valve, aortic valve closure function can be affected by various sinotubular junction and sinus diameter. Compared with the sinus diameters, sinotubular junction diameters have less effect on the performance of aortic valve closure, when the diameter difference is within a range of 20%. So surgical planning might give sinus diameter more consideration.

The Ross procedure: suitable for everyone?

In 1967, Donald Ross transferred the patient's own pulmonary valve into the aortic root. Although results of this technique were encouraging, the Ross procedure did not gain widespread popularity until the late 1980s when surgeons started to implant the pulmonary autograft as a freestanding full root replacement with reimplantation of the coronary arteries. However, frequent dilatation of the pulmonary autograft was observed using the freestanding full root replacement technique. In contrast, the original subcoronary implantation technique and aortic root inclusion technique prevented dilatation in the long-term. Through advancing know-how in aortic root surgery and confidence, the Ross procedure has also been used in combined procedures and complex clinical presentations with good long-term results, which encourage continual use. However, the Ross procedure is a complex operation; careful patient selection and experience of the surgeon are mandatory requirements to achieve satisfactory results.

The Ross operation: utilization of the patient’s own pulmonary valve as a replacement device for the diseased aortic valve

Prosthetic heart valves have been outpaced by progress in cardiac surgery. Early biologic valve prostheses consisted of tissues mounted on a rigid stent, and did not require anticoagulation, but rarely survived two decades. Subsequently, durable mechanical valve prostheses dominated despite, the requisite anticoagulation. The mechanical design remains imperfect, with obstruction to flow, turbulence, hematological changes and also, occasionally audible clicks. Reports documenting superior function for cryopreserved human aortic heart valves (homografts) without these problems, albeit with limited durability, followed. The marketing of 'stentless biologic valves', mimicking these attributes was a reaction to the shortage of homografts. These imperfections explain the rediscovery of the Ross operation, in which the patient's pulmonary valve (autograft) is excised to replace the aortic valve. The autograft is living tissue, complete with attributes of a healthy heart valve, including growth and durability. The pulmonary valve, where lower pressure and oxygen saturation retards degeneration, is substituted with a pulmonary homograft. The Ross operation is exacting and leaves the patient with two potentially malfunctioning valves.

The Ross procedure: outcomes at 20 years

OBJECTIVES

Our study examines the outcomes of the Ross procedure in a cohort of 212 patients prospectively followed with clinical and echocardiographic assessments.

METHODS

Patients' mean age was 34 ± 9 years; 66% were men and 82% had congenital aortic valve disease. The median follow-up was 13.8 years. Patients who had reoperations continued to be followed and entered into the survival analysis.

RESULTS

There was 1 operative death as well as 9 late deaths (3 in patients who no longer had the Ross). Survival at 20 years was 93.6% and similar to the general population matched for age and sex. Fifteen patients required reoperations on the pulmonary autograft (4 repairs and 11 replacements), 8 on the pulmonary homograft, and 4 other cardiac procedures. At 20 years the freedom from reoperation on the pulmonary autograft was 81.8% and on the pulmonary homograft was 92.7%, and in both was 79.9%. Preoperative aortic insufficiency, aortic annulus diameter ≥15 mm/m(2), and being a man were associated with increased risk of reoperation on the pulmonary autograft. Twenty-six patients developed aortic insufficiency greater than mild and 25 patients developed pulmonary homograft dysfunction (defined as moderate or severe insufficiency and/or peak systolic gradient of >40 mm Hg). At 20 years the freedom from aortic insufficiency was 62.6% and freedom from pulmonary valve dysfunction was 53.5%.

CONCLUSIONS

Survival after the Ross procedure in this cohort was similar to the general population. Dilated aortic annulus and aortic insufficiency were associated with increased risk of developing aortic insufficiency. Pulmonary homograft dysfunction was common at 20 years.

Rethinking the ross procedure in adults

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

When is the Ross operation a good option to treat aortic valve disease?

OBJECTIVE

We sought to identify suitable patients for the Ross operation.

METHODS

A cohort of 212 patients (mean age, 34 + or - 9 years; 66% men; 82% with congenital aortic valve disease) underwent the Ross operation and was prospectively followed with clinical evaluations and echocardiographic analysis for 3.1 to 18 years (mean, 10.1 + or - 4.2 years). In addition to longitudinal outcomes determined by means of Kaplan-Meier analysis, Cox regression analysis was used to identify predictors of valve failure.

RESULTS

There were 1 operative and 4 late deaths, none of which were valve related. Survival at 15 years was 96.6% + or - 1.5% and similar to that seen in the general population matched for age and sex. There were 20 reoperations: 13 in the pulmonary autograft, 3 in the pulmonary homograft, and 4 others. Freedom from reoperation in the pulmonary autograft at 15 years was 92.1% + or - 2.3%. Aortic insufficiency was the only independent predictor of reoperation. Freedom from moderate or severe aortic insufficiency at 15 years was 89.7%, and greater than mild aortic insufficiency was 63.2%. Male sex, aortic/pulmonary annular mismatch, aortic annulus of 27 mm or larger, and preoperative aortic insufficiency were associated with higher risk of late aortic insufficiency by means of log-rank analysis. Cox regression analysis identified male sex as the only independent predictor of postoperative aortic insufficiency. Freedom from moderate or severe pulmonary insufficiency, peak gradient of 40 mm Hg or greater, or both at 15 years was 70.8% + or - 6.8%, and event-free survival was 81% + or - 3.7%.

CONCLUSIONS

The Ross operation provided suboptimal results in male patients with aortic insufficiency. The best outcomes were in female patients, those with aortic stenosis, and those with an aortic annulus of less than 27 mm in diameter.

Autograft Reinforcement to Preserve Autograft Function After the Ross Procedure

Background— Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve autograft function and improve durability. The aim of this study is to evaluate this hypothesis.

Methods and Results— 1335 adult patients (mean age:43.5±12.0 years) underwent a Ross procedure (subcoronary, SC, n=637; root replacement, Root, n=698). 592 patients received R of the annulus, sinotubular junction, or both. Regular clinical and echocardiographic follow-up was performed (mean:6.09±3.97, range:0.01 to 19.2 years). Longitudinal assessment of autograft function with time was performed using multilevel modeling techniques. The Root without R (Root−R) group was associated with a 6× increased reoperation rate compared to Root with R (Root+R), SC with R (SC+R), and without R (SC-R; 12.9% versus 2.3% versus 2.5%.versus 2.6%, respectively; P <0.001). SC and Root groups had similar rate of aortic regurgitation (AR) development over time. Root+R patients had no progression of AR, whereas Root−R had 6 times higher AR development compared to Root+R. In SC, R had no remarkable effect on the annual AR progression. The SC technique was associated with lower rates of autograft dilatation at all levels of the aortic root compared to the Root techniques. R did not influence autograft dilatation rates in the Root group.

Conclusions— For the time period of the study surgical autograft stabilization techniques preserve autograft function and result in significantly lower reoperation rates. The nonreinforced Root was associated with significant adverse outcome. Therefore, surgical stabilization of the autograft is advisable to preserve long-term autograft function, especially in the Root Ross procedure.

Aortic stenosis and aortic insufficiency in children: impact of valvuloplasty and modified Ross-Konno procedure

Aortic stenosis and aortic insufficiency in young children present multiple challenges to the patient, family, and surgeon. Mechanical valves require anticoagulation therapy, which is a poor option in active youngsters and noncompliant adolescents. Aortic valvuloplasty and the various forms of the Ross/Ross-Konno operations appear to be good solutions in this patient population due to valve preservation for the former and autograft growth for the latter. However, valvuloplasty failure and autograft dilatation have developed in some patients. In addition, heart block remains a problem in those patients who require an annular enlarging operation. We review our experience with the various forms of valvuloplasty, Ross operation, Konno operation, Ross-Konno operation, and the modified Ross-Konno operation, which we have used to eliminate heart block in patients who require an annular enlarging operation.

Accuracy of intraoperative transesophageal echocardiography in the prediction of future neo-aortic valve function after the Ross procedure in children and young adults

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.

The Ross Operation in Children: Effects of Aortic Annuloplasty

BACKGROUND

Autograft dilatation and progressive neoaortic regurgitation after the Ross procedure prompted us to perform routine aortic annuloplasty. The purpose of this review is to evaluate the success of this technical modification in preventing autograft failure requiring reoperation.

METHODS

From 1994 to 2005, 46 children and young adults with a mean age of 12.9 +/- 4.9 years (range, 14 months to 21 years) underwent a Ross procedure; 19 of 46 patients had prior aortic valve surgery. Neoaortic valve function and need for reintervention were compared between patients who had a Ross procedure without annuloplasty (n = 20) and those who had an annular reduction prior to the autograft anastomosis (n = 26).

RESULTS

There were no early or late deaths during a mean follow-up of 65 +/- 36 months. Mean hospital stay was 6.6 +/- 2.9 days. Two patients required early intervention (eight days) for significant neoaortic regurgitation; one patient required repair of a left ventricular outflow tract pseudoaneurysm a month after emergent Ross procedure for endocarditis, and one patient required replacement of a stenotic homograft at five years. Five patients (13%) required autograft repair (n = 3) or replacement (n = 2) for progressive neoaortic regurgitation, two of the 26 patients had reduction annuloplasty (8%), and three of the 20 patients did not (15%) (p = 0.6). There was a similar incidence of neo-sinus of Valsalva dilatation 37 mm or greater in patients with (53%) and without (36%) annuloplasty (p = 0.5).

CONCLUSIONS

The Ross procedure remains an excellent option for valve replacement in children and young adults given the alternatives and can be performed with very low mortality. However, in this series of Ross operations in children, routine use of aortic annuloplasty failed to prevent neoaortic regurgitation requiring reoperation.

The Relationship Between Neo-Aortic Root Dilation, Insufficiency, and Reintervention Following the Ross Procedure in Infants, Children, and Young Adults

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.

Geometric models of the aortic and pulmonary roots: suggestions for the Ross procedure

OBJECTIVE

To discuss geometric factors, which may influence long-term results relating to homograft competence following the Ross procedure, we describe the 3D morphology of the pulmonary and aortic roots.

MATERIALS

Measurements were made on 25 human aortic and pulmonary roots. Inter-commissural distances and the heights of the sinuses were measured. For geometrical reconstruction the three commissures and their vertical projections at the root base were used as reference points.

RESULTS

In the pulmonary root, the three inter-commissural distances were of similar dimensions (17.9+/-1.6mm, 17.5+/-1.4mm and 18.6+/-1.5mm). In the aortic root, the right inter-commissural distance was greatest (18.8+/-1.9mm), followed by the non-coronary (17.4+/-2.0mm) and left coronary sinus commissures (15.2+/-1.9mm). The mean height of the left pulmonary sinus was greatest (20+/-1.7mm) followed by the anterior (17.5+/-1.4mm) and right pulmonary sinus (18+/-1.66mm). In the aortic root, the height of the right coronary sinus was the greatest (19.4+/-1.9mm) followed by the heights of the non-coronary (17.7+/-1.8mm) and left coronary sinus (17.4+/-1.4mm). Measured differences between parameters determine the tilt angle and direction of the root vector. The tilt angle in the pulmonary root averaged 16.26 degrees , respectively; for the aortic roots, it was 5.47 degrees .

CONCLUSIONS

Herein we suggest that the left pulmonary sinus is best implanted in the position of the right coronary sinus, the anterior pulmonary in the position of the non-coronary sinus and the right pulmonary sinus in the position of the left coronary sinus. In this way, the direction of the pulmonary root vector will be parallel to that of the aortic root vector.

The Ross Procedure: New Insights Into the Surgical Anatomy

BACKGROUND

The precise knowledge of regional anatomical details is of utmost importance specially in complex procedures such as the Ross operation. This anatomical study offers a critical approach regarding the advantages, limits, and precautions for this procedure.

METHODS

Using dissection techniques, magnifications up to x6 and nontraditional approaches, 68 fixed normal heart specimens were studied over a 2-year period. The details of surgical relevance such as the boundaries and relations of the pulmonary and aortic roots, their vascularization, and the number and distribution of the septal arteries are described.

RESULTS

The aortic and pulmonary roots include interdependent elements functioning in a coordinated manner and establishing important relations with adjacent structures. Both coronary arteries vascularize the arterial roots. The infundibular branches from the right coronary artery are larger and more constant. The septal arteries establish important relations with the pulmonary infundibulum but their contribution to its vascularization is negligible. In this series, the main septal artery was the second, showing the longest retroinfundibular course. However, no constant relation was found between this vessel and the intraventricular landmarks.

CONCLUSIONS

A novel approach was used by performing nontraditional dissections of the arterial roots and by studying their vascularization The depicted details are useful to the surgeon specializing in the Ross procedure and represent the basis for further research.

Ross Procedure and Left Ventricular Mass Regression

Background— Return of left ventricular mass to normal is considered to be a favorable result of aortic valve replacement. The Ross procedure provides near normal hemodynamics and thus allows studies of left ventricular (LV) reverse remodeling. LV mass regression may be influenced by surgical technique (subcoronary [SC] versus root replacement [RR]).

Methods and Results— Data from the German Ross Registry were analyzed. A total of 646 patients (mean age: 43.6±12.7 years, range: 16 to 71 years; SC technique n=295, RR technique n=351) underwent a Ross procedure in 7 participating centers from 1990 to 2004. The patients underwent preoperative and postoperative echocardiographic evaluations. Mean follow-up time was 3.5±2.5 years (range 0.12 to 13.7 years). Follow-up completeness was 97%. The LV mass index (LVMI) decreased significantly during follow-up in both groups (SC: 209±53 preoperatively to 154±48 at 1-year follow-up, [ P <0.01 versus preoperative values] to 149±51g/m 2 at 2-year follow-up, [ P =NS 1-year versus 2-year follow-up] versus RR: from 195±56 preoperatively to 144±51 at 1-year follow-up [ P <0.01 versus preoperative values] to 140±49g/m 2 [ P =NS 1-year versus 2-year follow-up]). LVMI regression remained stagnant 1 year after the Ross procedure in most patients in both groups. On the basis of multivariate analysis, predictors for incomplete LVMI regression after the autograft procedure were high preoperative LVMI, smoking, and uncontrolled diastolic hypertension.

Conclusions— At mid-term echocardiographic follow-up, patients of both groups had favorable autograft hemodynamics. Risk factors for incomplete postoperative LVMI regression in our study were smoking and persistent diastolic hypertension. This emphasizes the importance of cessation of smoking and treatment of arterial hypertension, even in younger patients, after corrected aortic valve disease.

Aortic Valve Replacement With the Pulmonary Autograft: Mid-Term Results

BACKGROUND

The purpose of this study is to assess the mid-term results of aortic valve replacement with the pulmonary autograft.

METHODS

From October 1993 through September 2003, 153 patients with aortic valve disease (81 rheumatic and 72 non-rheumatic), with a mean age of 28 +/- 14.2 years underwent the Ross procedure with root replacement technique and right ventricular outflow tract reconstruction using a homograft. Associated procedures included mitral valve repair (n = 19), open mitral commissurotomy (n = 15), tricuspid valve repair (n = 2), homograft mitral valve replacement (n = 2), and subaortic membrane resection (n = 1).

RESULTS

Early mortality was 6.5% (10 patients). Mean follow-up was 77 +/- 42 months (range, 7 to 132 months; median, 90 months). One hundred, twenty-one survivors (84.6%) had no significant aortic regurgitation. Reoperation was required in 10 patients for autograft dysfunction alone (n = 3), infective endocarditis (n = 2), autograft dysfunction with failed mitral valve repair (n = 3), and failed mitral valve repair alone (n = 2). No reoperations were required for the pulmonary homograft. There were 8 late deaths. Actuarial and reoperation-free survival at 90 months were 91.% +/- 3.5%, 95.3% +/- 2.7%, in non-rheumatics and 86.1 +/- 3.9%, 90.5 +/- 3.7% in rheumatics, respectively. Freedom from significant aortic stenosis or regurgitation was 91.5 +/- 2.8% in non-rheumatics and 80.6 +/- 4.8% in rheumatics. Event-free survival was 86.2 +/- 4.9% in non-rheumatics and only 68.9 +/- 5.3% in rheumatics.

CONCLUSIONS

The Ross procedure is not recommended for young patients (< 30 years) with rheumatic heart disease. It provides satisfactory hemodynamic and clinical results in properly selected patients. Important autograft dilatation was not observed in our patients.

Risk Factors, Dynamics, and Cutoff Values for Homograft Stenosis After the Ross Procedure

BACKGROUND

The purpose of this study was to find homograft-related factors that might be associated with the development of stenosis after the Ross procedure, as well as to identify the natural dynamics of stenosis and find echographic cutoff values after one year of follow-up that might predict such an outcome.

METHODS

We followed up 71 patients (mean age, 24.27 +/- 16.57 years) who had such a procedure prospectively by transthoracic echocardiography, between 1993 and 2002. Follow-up was 55.26 +/- 29.63 months and was 90.14% complete. Homografts were harvested from heart-beating donors or cardiac transplant recipients. Allograft stenosis was analyzed and risk factors were identified by univariate, multivariate, and survival analysis methods. Stenosis was defined as a mean gradient greater than or equal to 20 mm Hg.

RESULTS

There were two reoperations and 21 homografts were stenotic at the last follow-up, ten of which were already so at one year after the procedure. Cox regression analysis revealed a transhomograft gradient greater than 9 mm Hg at 1 year after the procedure (hazard ratio [HR] = 10.04) and homograft size (HR = 0.75) as independent predictors for stenosis. Stenosis-free survival was 85.94 +/- 4.35%, 75.51 +/- 5.55%, and 68.56 +/- 6.34 after 1, 3, and 5 years, respectively. A cutoff value of 9 mm Hg at 1 year of follow-up could predict different stenosis-free survival rates.

CONCLUSIONS

Homograft size is the most important homograft-related factor for stenosis. Most of the increase in transhomograft gradient occurs in the first 24 months. A gradient of 9 mm Hg or more after 1 year predicts the late occurrence of stenosis.

The Ross Operation: An Evaluation of a Single Institution's Experience

BACKGROUND

Pulmonary autograft aortic root replacement was used in adults. Risk factors for aortic valve incompetence (AI) and pulmonary homograft valve stenosis are identified.

METHODS

From February 1991 through May 2003, 103 patients, with a mean age of 35.2 +/- 9.5 years, underwent aortic root replacement with the pulmonary autograft. Annulus reinforcement (reduction annuloplasty or use of root ring) was carried out in 45 patients. In all but 1 patient, the right ventricular outflow tract was reconstructed with a cryopreserved pulmonary homograft. Mean follow-up duration was 6.0 +/- 2.8 years (range 0.3 to 11 years).

RESULTS

There were no hospital deaths. Overall patient survival was 98.9 +/- 1.0% at 1 year and 97.3 +/- 1.9% at 10 years. Autograft function follow-up resulted in 5 patients requiring reoperation for aortic incompetence. The univariate risk factors for aortic incompetence at discharge and during follow-up were respectively annulus reinforcement (p = 0.05) and bicuspic aortic valve (p = 0.05). Reoperation for homograft failure occurred in 1 patient. During follow-up, 24 patients (25.5%) developed homograft stenosis (gradient > 20 mm Hg). Univariate analysis indicated the diameter of the homograft (p = 0.001) as factor associated with stenosis during follow-up. Cox regression identified smaller diameter of the homograft (p = 0.001) and older age of donor (p = 0.002) as independent risk factor for the development of homograft stenosis.

CONCLUSIONS

The Ross operation can be performed with few complications. Although both the aortic autograft and the pulmonary homograft have limited durability, this has not yet resulted in considerable reoperation rates and associated morbidity and mortality.

The Southern Thoracic Surgical Association 50th anniversary celebration: the impact of STSA pediatric cardiothoracic surgery manuscripts on surgical practice

BACKGROUND

Members of the Southern Thoracic Surgical Association (STSA) have presented important pediatric cardiothoracic surgery papers at the annual meetings over the last 50 years. In order to determine the influence of these presentations on the practice of surgery, a review was undertaken. Early papers were characterized by emerging advances in open-heart surgery, anatomic congenital heart studies, and electrophysiologic discoveries that extended life with pacemakers. Later years were characterized by innovative myocardial preservation methods, improved cardiopulmonary bypass techniques, expanded homograft availability, emphasis on accurate repairs, intraoperative transesophageal echocardiography, and cardiopulmonary transplantation.

METHODS

All but one of the scientific programs of the annual meetings (that of 1964) were located. The programs were reviewed and 180 presentations were identified on topics in congenital heart disease, pediatric thoracic disease, and pediatric thoracic wall abnormalities. Of those 180 oral presentations, 155 manuscripts (86%) were eventually published or in press and available for critical review and analysis. Manuscripts were grouped by diagnosis or therapeutic intervention. We determined a "cumulative citation frequency" (CCF), which measures the number of times an article is cited in the bibliography of related papers in the universe of participating journals. The selected manuscripts were compared with the historic landmark contributions and the existing trends at the time, and the number of articles both by individual authors and from institutions were tallied.

RESULTS

Grouping by authors and institutions showed that 100 of 155 pediatric cardiothoracic manuscripts (65%) originated from 13 institutions. The CCF for the 20 leading articles ranged from 26 to 93.

CONCLUSIONS

This historical STSA 50-year record of pediatric cardiothoracic advances was accomplished in a milieu of collegial respect and camaraderie. Our annual meetings over the years have provided a venue for thoracic surgeons to share their ideas, innovations, and scientific inquiry. These contributions have significantly affected the practice of pediatric cardiothoracic surgery. The STSA has worked for 50 years and we trust that it will work for another 50 years and beyond.

The Ross procedure in adults: intermediate-term results

BACKGROUND

The durability of the Ross procedure may be optimized by appropriate geometric matching of the aortic and pulmonary artery roots. We employed a surgical strategy to standardize the operation in order to avoid more readily a geometric mismatch.

METHODS

The Ross procedure was performed as a root replacement. Without regard for patient body surface area, the aortic annulus was plicated to 23 mm and externally buttressed with felt. Geometric mismatch of the distal autograft anastomosis was avoided by liberal use of a synthetic interposition graft, and the anastomosis was also externally buttressed with felt. An over-sized pulmonary homograft (27 to 28 mm) was routinely used to reconstruct the right ventricular outflow tract.

RESULTS

Forty-four consecutive patients (27 men and 17 women; mean age, 49 +/- 9 years) were operated on between January 1997 and March 2002. Mean follow-up was 38 +/- 5 months. Twenty-nine patients had aortic stenosis and 15 had aortic regurgitation. Aortic annular plication was done in 41 (93%) and an aortic interposition was used in 14 (32%). There were three hospital deaths, with no subsequent deaths. Only 1 patient required reoperation 2.5 years postoperatively from recurrent endocarditis. No patient has more that "trivial" autograft insufficiency, and the mean autograft gradient was 7 +/- 3 mm Hg. No patient has significant pulmonary homograft stenosis.

CONCLUSIONS

Geometric matching of the aortic and pulmonary roots may be readily accomplished using a standardized approach to the Ross procedure. In turn, this may optimize the durability of the operation.

Comparison of autograft and allograft aortic valve replacement in children

OBJECTIVE

This study was undertaken to compare the clinical and hemodynamic results following aortic valve replacement with a pulmonary valve autograft (Ross procedure) or an allograft valve in children.

METHODS

The records of 107 pediatric aortic valve replacements from 1994 through 2001 were reviewed, including 78 autografts and 25 allografts. Four mechanical aortic valve replacements performed during this period were excluded from analysis.

RESULTS

There were 3 perioperative deaths and 1 late death. Reoperations were required in 5 autograft recipients (with autograft preservation in 4) and in 3 allograft recipients (all requiring valve re-replacement). Seven-year survival (96% in both groups) and reoperation-free survival (88% in the autograft group; 73% in the allograft group, P =.5) were not significantly different. Serial echocardiographic studies showed that in the autograft group, left ventricular outflow tract maximal velocity (2.0-1.8 m/s, P =.02) and left ventricular thickness (10.1-8.4 mm, P <.0001) fell significantly. In the allograft group, maximal velocity (2.3-3.0 m/s, P =.03) increased significantly and left ventricular thickness (9.5-9.0 mm, P =.2) showed minimal change. Analysis according to preoperative physiology (aortic stenosis versus insufficiency), congenital cardiac anatomy, number or type of previous operations, age of patient, and use of balloon valvotomy did not predict outcomes.

CONCLUSIONS

Aortic valve replacement with either the autograft or allograft provides excellent clinical results in children during an intermediate duration of observation. The Ross procedure achieves a superior hemodynamic result, which may be clinically important with longer follow-up.

Does intraoperative transesophageal echocardiography predict pulmonary valve dysfunction during the Ross procedure?

OBJECTIVE

To determine the value of intraoperative transesophageal echocardiography for the assessment of the pulmonary valve anatomy and the pulmonary autograft performance in patients undergoing the Ross procedure.

DESIGN

Open, prospective, observational survey.

SETTING

Favaloro Foundation, single institution.

PARTICIPANTS

Consecutive patients undergoing elective Ross procedure (n = 87).

INTERVENTIONS

Pulmonary valve function and anatomy were assessed by transesophageal echocardiography and the surgeon. Pulmonary autograft function was assessed after implantation. Regurgitation was considered mild (+/4), moderate (++/4), moderate-to-severe (+++/4), and severe (++++/4). Patients were restudied during midterm follow-up.

MEASUREMENTS AND MAIN RESULTS

The Ross procedure was done in 74 patients (85%). Overall mortality was 3.4%. Mean follow-up was 24 +/- 13 months. The Ross procedure was not done in 13 patients (15%): 6 patients had a bicuspid pulmonary valve, 6 patients had >3 mm fenestrations, and 1 patient had regurgitation. The surgeon diagnosed anomalies in the pulmonary valve through direct observation. Transesophageal echocardiography was not sensitive enough to diagnose pulmonary valve defects in 12 of 13 patients with anomalies. Pulmonary valve regurgitation was identified by intraoperative transesophageal echocardiography in only 1 patient. Autograft regurgitation was 1.07 +/- 0.35 at postoperative evaluation. At 1, 6, and 12 months, it was 1.25 +/- 0.7 (p = 0.18), 1.27 +/- 0.9 (p = 0.185), and 1.29 +/- 0.8 (p = 0.17). The difference in values was not statistically significant. Four patients (5.4%) showed an increase in regurgitation during the first transthoracic autograft control.

CONCLUSION

Intraoperative transesophageal echocardiography allows assessment of autograft performance after implantation. This method is not helpful, however, in detecting pulmonary valve anatomic anomalies.

Mid-term results of the Ross procedure

Although the Ross procedure has been performed for over three decades, its role in the management of patients with aortic valve disease is not well established. This study reviews our experience with this operation. From 1990 to 1999, 155 patients underwent the Ross procedure. The mean age of 106 men and 49 women was 35 years. Most patients (85%) had congenital aortic valve disease. The pulmonary autograft was implanted in the subcoronary position in 2 patients, as an aortic root inclusion in 78, and aortic root replacement in 75. The follow-up extended from 9 to 114 months, mean of 45 +/- 28 months, and it was complete. All patients have had Doppler echocardiographic studies. There was only one operative and one late death. The survival was 98% at 7 years. The freedom from 3+ or 4+ aortic insufficiency was 86% at 7 years and the freedom from reoperation on the pulmonary autograft was 95% at 7 years. Dilation of the aortic annulus and/or sinotubular junction was the most common cause of aortic insufficiency. One patient required three reoperations on the biological pulmonary valve. Most patients (96%) have no cardiac symptoms. The Ross procedure has provided excellent functional results in most patients, but progressive aortic insufficiency due to dilation of the aortic annulus and/or sinotubular junction is a potential problem in a number of patients.

Ross operation for bicuspid aortic valve disease in adults: is it a valid surgical option?

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.

Technique of pulmonary autograft aortic valve replacement in children (the Ross procedure)

Pulmonary autograft replacement has become a popular technique for relieving left ventricular outflow tract obstruction in children with aortic valvular or subvalvular disease. The advantages of the autograft are the avoidance of prosthetic valves that require anticoagulation and the potential for growth of a viable autograft aortic valve. Although many techniques for implantation of the autograft in the aortic outflow tract have been described, the most commonly preferred technique is the use of the autograft as a root replacement with reimplantation of the coronary ostia. This technique provides the optimal geometry of the autograft commissural attachments and also permits adjustment of the aortic annulus to enlarge the subaortic region in patients with complex left ventricular outflow tract obstruction or to narrow the aortic annulus in patients with primary aortic regurgitation and annular dilatation. Use of the autograft technique in children and young adults has resulted in excellent relief of outflow tract obstruction with low operative morbidity and mortality, and the intermediate results have been encouraging. The variations in surgical technique that have evolved have the potential to decrease the risk of late redilatation and regurgitation of the autograft valve and may provide better longevity. Copyright 1998 by W.B. Saunders Company

A new modified Bentall procedure: the flanged technique

Replacement of the aortic root with a composite graft containing a prosthetic mechanical valve is the preferred surgical procedure for tailoring the aortic root. A new composite graft is designed with an extension below the prosthetic valve. The flange of the graft is anastomosed to the aortic annulus with a continuous suture. The remainder of the procedure is performed in the usual fashion, with button coronary anastomoses. This method is an alternative to previously described Bentall procedures for all aortic root pathologies, especially in cases with small aortic root precluding root enlargement and in those with defects at the annular and subannular areas that require repair.

Technical evolution of the Ross operation: midterm results in 186 patients

BACKGROUND

The Ross operation approaches the ideal aortic valve replacement. Between February 1995 and February 2000 we performed 186 procedures. This article reviews modifications introduced reflecting our experience.

METHODS

In all patients the Ross operation was performed as root replacement. Echocardiographic follow-up was complete in 94% of patients.

RESULTS

No operative death or early mortality occurred, nor did thromboembolic or hemorrhagic events. One patient died at 25 months from hemoptysis with pulmonary valve vegetations. Three patients required reoperation for autograft insufficiency. In 1 patient a tethered cusp was repairable and in 2 patients progressive autograft dilatation required autograft replacement. After routinely incorporating support into the aortic annulus and replacing all dilated ascending aorta, autograft dilatation did not recur. For the pulmonary homograft, one outflow patch was placed to relieve a symptomatic gradient. Nine patients with elevated gradients were under observation. Echocardiography revealed autograft median peak systolic gradients of 4.6+/-2.8 mm Hg, pulmonary homograft gradients of 14.8+/-9.6 mm Hg, and nil or insignificant regurgitation.

CONCLUSIONS

The aortic annulus must be supported and the dilated ascending aorta replaced. Root replacement with a short autograft allows consistent results. Pulmonary homograft dysfunction is rare but unpredictable.

Hemodynamic performance during maximum exercise in adult patients with the ross operation and comparison with normal controls and patients with aortic bioprostheses

This study examines the resting and exercise hemodynamic performance of the pulmonary autografts in the aortic position as well as of the homografts used for right ventricular outflow reconstruction in patients undergoing the Ross operation. Previous studies have reported excellent resting hemodynamics in patients who underwent aortic valve replacement with a pulmonary autograft. However, there are very few studies of their hemodynamic performance during exercise. Twenty adult subjects who underwent the Ross operation and 12 normal control subjects were submitted to maximum romp bicycle exercise. The valve effective orifice areas and transvalvular gradients of both aortic (autograft) and pulmonary (homograft) valves were measured at rest and at peak of maximum exercise using Doppler echocardiography. Valve areas were indexed for body surface area. The hemodynamics of the aortic valve were very similar in Ross subjects and in control subjects at rest and during exercise. However, the indexed valve area of the pulmonary valve at rest was significantly (p < 0.001) lower in the Ross subjects (1.10 +/- 0.46 cm2/ m2) than in the control subjects (1.95 +/- 0.41 cm2/m2), resulting in higher (p = 0.004) mean gradients at rest (Ross: 9 +/- 7 mm Hg vs control: 2 +/- 1 mm Hg) and at peak exercise (Ross: 21 +/- 14 mm Hg vs control: 7 +/- 2 mm Hg). The pulmonary autograft provided excellent hemodynamics in the aortic position either at rest or during maximum exercise, whereas moderately high gradients were found during exercise across the homograft implanted in the pulmonary valve position. Future improvement of the Ross procedure should be oriented toward the search of new methods to prevent the deterioration of the homografts.