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Dib N, Ducruet T, Poirier N, Khairy P. The Ross-Konno Procedure With or Without Mitral Valve Surgery: A Systematic Review With Individual Data Pooling. World J Pediatr Congenit Heart Surg 2024; 15:411-418. [PMID: 38454620 DOI: 10.1177/21501351241232075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Background: The Ross-Konno procedure is a technically demanding surgical option to treat multilevel left ventricular outflow tract obstruction. Methods: A systematic review with pooled analyses was conducted according to PRISMA criteria on studies published between January 2000 and May 2022 that assessed outcomes following the Ross-Konno intervention in children. Individual patient data were extracted from published Kaplan-Meier curves using digitalization software. Overall survival and freedom from reintervention were assessed by time-to-event approaches. Determinants of one-year survival were investigated by meta-regression analyses. Results: Ten studies with a total population of 274 patients were included. The overall pooled early (≤30 days) survival rate was 86.9% (95% CI [87.6%-78.4%]). Five-year survival rates in patients without and with (N = 50 [18.2%] of 274 total patients) concomitant mitral valve surgery were 82.5% (95% CI [87.6%-77.4%]) versus 56.1% (95% CI [74.1%-38.1%]), hazard ratio 2.67, 95% CI (1.44-4.93), P < .0001. Five- and ten-year freedom from pulmonary autograft reoperation rates were 93.5% and 90.9%, respectively. Five- and ten-year freedom from right ventricular outflow tract reoperation rates were 74.3% and 57.3%, respectively. By meta-regression analysis, resection of endocardial fibroelastosis (N = 32 [11.7%] of 274 total patients) was associated with superior one-year survival (P = .027). Conclusion: The Ross-Konno procedure is associated with substantial early mortality and gradual attrition thereafter. Mortality is higher in patients with concomitant mitral valve surgery. Resection of endocardial fibroelastosis is associated with superior survival. Right ventricular outflow tract reinterventions are common.
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Affiliation(s)
- Nabil Dib
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Division of Cardiac Surgery, Department of Surgery, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Thierry Ducruet
- Unité de Recherche Clinique Appliquée, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Nancy Poirier
- Division of Cardiac Surgery, Department of Surgery, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Paul Khairy
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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Dib N, Ben Ali W, Ducruet T, Trudeau O, Bernier PL, Poirier N, Khairy P. The Ross Procedure in Children and Infants: A Systematic Review With Pooled Analyses. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2024; 3:117-124. [PMID: 39070957 PMCID: PMC11282879 DOI: 10.1016/j.cjcpc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 07/30/2024]
Abstract
Background The Ross procedure is a surgical option for congenital aortic stenosis that involves replacing the diseased aortic valve with a pulmonary autograft. Little is known about outcomes in children, particularly those younger than 1 year. Methods A systematic review with pooled analyses was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Inferred individual patient data were extracted from life tables. The primary end points were early (≤30 days) and late (>30 days) mortality rates following the Ross procedure in children. Secondary end points were freedom from reintervention for the right ventricular outflow tract and pulmonary autograft. These end points were assessed in the overall population of children. Sensitivity analyses were performed in subgroups younger than 1 year of age (infants) and in noninfant children. Results A total of 25 studies on 2737 patients met inclusion criteria. The pooled early survival rate was 96.0% (95% confidence interval [CI]: 95.1%-96.8%) overall and 86.8% (95% CI: 82.1%-90.3%) among infants. Pooled overall 10-year survival, freedom from pulmonary autograft reintervention, and freedom from right ventricular outflow tract reintervention rates were 91.1%, 90.2%, and 79.7%, respectively. Corresponding pooled rates in infants were 79.3%, 87.1%, and 51.2%. Mortality was significantly higher among infants compared with noninfant children (hazard ratio: 3.38, 95% CI: 2.44-4.68; P < 0.001). In metaregression analyses, younger age was strongly associated with poorer survival and higher reintervention rates. Conclusions Modest survival and autograft reoperation rates were observed following the Ross procedure in children. Surgery in infancy was strongly associated with poorer survival and higher reintervention rates.
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Affiliation(s)
- Nabil Dib
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
- Division of Cardiac Surgery, Department of Surgery, Sainte-Justine Hospital, Université de Montréal, Montreal, Québec, Canada
| | - Walid Ben Ali
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Thierry Ducruet
- Unité de Recherche Clinique Appliquée, Sainte-Justine Hospital, Université de Montréal, Montreal, Québec, Canada
| | - Ofélie Trudeau
- Unité de Recherche Clinique Appliquée, Sainte-Justine Hospital, Université de Montréal, Montreal, Québec, Canada
| | - Pierre-Luc Bernier
- Division of Cardiac Surgery, Department of Surgery, Sainte-Justine Hospital, Université de Montréal, Montreal, Québec, Canada
| | - Nancy Poirier
- Division of Cardiac Surgery, Department of Surgery, Sainte-Justine Hospital, Université de Montréal, Montreal, Québec, Canada
| | - Paul Khairy
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
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Dib N, Iriart X, Belaroussi Y, Albadi W, Tafer N, Thambo JB, Khairy P, Roubertie F. The Ross Operation in Young Patients: A 15-Year Experience Focused on Right Ventricle to Pulmonary Artery Conduit Outcomes. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:86-92. [PMID: 37970525 PMCID: PMC10642144 DOI: 10.1016/j.cjcpc.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/20/2022] [Indexed: 11/17/2023]
Abstract
Background Data on long-term outcomes of the Ross operation in children and young adult patients are limited. The best pulmonary valve substitute for the right ventricular outflow tract reconstruction remains uncertain. This study aimed to assess the outcomes of right ventricular outflow tract reconstruction in the Ross operation in young patients using various pulmonary valve substitutes at a single institution. In addition, a comparison of reintervention rates between patients younger than 18 years and those older than 18 years was performed. Methods The study assessed all patients (N = 110) who underwent the Ross operation at the University Hospital of Bordeaux, France, between 2004 and 2020. Results The median follow-up time was 4.2 years, and the median age at operation was 15.9 years. There was no operative mortality and 1 late noncardiac death (0.8%). The overall survival rate at 10 years was 99.2%. The need for right ventricular outflow tract reoperation was lower with the pulmonary homograft compared with the Contegra conduit and Freestyle bioprosthesis: 94.3%, 93.8%, and 80% at 5 years, respectively, and 94.3%, 72.3%, and 34.3% at 10 years, respectively (P = 0.011). The probability of reintervention was not significantly different at 10 years among children vs adults (P = 0.22). Conclusions The Ross procedure in children and young adults was associated with a lower requirement for right ventricular outflow tract reoperation when pulmonary homografts were used instead of xenografts.
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Affiliation(s)
- Nabil Dib
- Department of Congenital Cardiac surgery, Bordeaux Heart University Hospital, University of Bordeaux II, Bordeaux, France
| | - Xavier Iriart
- Department of Congenital Cardiology, Bordeaux Heart University Hospital, University of Bordeaux II, Bordeaux, France
| | - Yaniss Belaroussi
- Department of Congenital Cardiac surgery, Bordeaux Heart University Hospital, University of Bordeaux II, Bordeaux, France
| | - Waleed Albadi
- Department of Congenital Cardiac surgery, Bordeaux Heart University Hospital, University of Bordeaux II, Bordeaux, France
| | - Nadir Tafer
- Department of Congenital Cardiac Anesthesiology, Bordeaux Heart University Hospital, University of Bordeaux II, Bordeaux, France
| | - Jean-Benoit Thambo
- Department of Congenital Cardiology, Bordeaux Heart University Hospital, University of Bordeaux II, Bordeaux, France
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - François Roubertie
- Department of Congenital Cardiac surgery, Bordeaux Heart University Hospital, University of Bordeaux II, Bordeaux, France
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Fernández-Carbonell A, Rodríguez-Guerrero E, Merino-Cejas C, Conejero-Jurado MT, Villalba-Montoro R, Romero-Morales MDC, Alados-Arboledas P, Casares-Mediavilla J, Fernández-Carbonell M, López-Cillero P, Caro-Barrera JR. Predictive Factors for Pulmonary Homograft Dysfunction After Ross Surgery: A 20-Year Follow-up. Ann Thorac Surg 2020; 111:1338-1344. [PMID: 32827551 DOI: 10.1016/j.athoracsur.2020.06.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/31/2020] [Accepted: 06/08/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND We studied the determinants of hemodynamics and analyzed the incidence, risk factors, and clinical impact of pulmonary homograft dysfunction following Ross surgery, after a 20-year follow-up at our referral center. METHODS From 1997 to 2017, a total of 142 patients underwent surgery using the Ross procedure. The development of moderate-severe stenosis (peak transhomograft pressure gradient 36 mm Hg or greater) and surgical or percutaneous Ross homograft reinterventions were evaluated by echocardiography in the immediate postoperative period and at annual intervals. RESULTS After 20 years of follow-up, 31% of patients had moderate-severe homograft stenosis, and 9.1% had had to undergo one or two reinterventions, of which, six were valve replacements and seven were percutaneous interventions. At 1, 5, and 20 years, 89.4%, 74.6%, and 69% of these patients, respectively, were free from moderate-severe stenosis; and 99.3%, 95.7%, and 90.9%, respectively, had freedom from homograft reintervention. The pediatric group had a higher risk factor for homograft stenosis (hazard ratio 3.70; 95% confidence interval, 1.56 to 7.20, P = .002), whereas donor age behaved as a protective factor (hazard ratio 0.98; 95% confidence interval, 0.95 to 0.99; P = .044). Pulmonary homograft stenosis tended to appear in the first year (10.6%) or at 5 years (25.4%). CONCLUSIONS Pulmonary homografts implanted in the Ross procedure offer satisfactory long-term results, but the level of homograft dysfunction is not negligible. Young recipient and donor age were associated with a higher rate of homograft stenosis during follow-up. Moreover, homograft dysfunction usually occurred during the first few years of follow-up, and may have been related to immune responses.
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Affiliation(s)
| | | | - Carlos Merino-Cejas
- Department of Cardiovascular Surgery, Reina Sofía University Hospital, Córdoba, Spain
| | | | - Rafael Villalba-Montoro
- Regional Blood Transfusion Center and Tissue Bank, Reina Sofía University Hospital, Córdoba, Spain
| | | | | | | | | | - Pedro López-Cillero
- Hepatobiliary Surgery and Liver Transplant Service, Reina Sofía University Hospital, Córdoba, Spain
| | - José Rafael Caro-Barrera
- Department of Statistics, Econometrics, and Operational Research, University of Córdoba, Córdoba, Spain
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Pulmonary homograft stenosis in the Ross procedure: Incidence, clinical impact and predictors in long-term follow-up. Arch Cardiovasc Dis 2017; 110:214-222. [PMID: 28043783 DOI: 10.1016/j.acvd.2016.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Ross procedure is used in the treatment of selected patients with aortic valve disease. Pulmonary graft stenosis can appear in the long-term follow-up after the Ross intervention, but the factors involved and its clinical implications are not fully known. AIM To describe the incidence, clinical impact and predictors of homograft stenosis and reintervention after the Ross procedure in a prospective series in a tertiary referral hospital. METHODS From 1997 to 2009, 107 patients underwent the Ross procedure (mean age: 30±11 years; 69% men; 21 aged<18 years), and were followed for echocardiographic homograft stenosis (peak gradient>36mmHg) and surgical or percutaneous homograft reintervention. RESULTS After 15 years of follow-up (median: 11 years), echocardiographic and clinical data were available in 91 (85%) and 104 (98%) patients, respectively: 26/91 (29%) patients developed homograft stenosis; 10/104 (10%) patients underwent 13 homograft reintervention procedures (three patients underwent surgical replacement, three received a percutaneous pulmonary valve and one needed stent implantation). The other three patients underwent two consecutive procedures in follow-up; one died because of a procedure-related myocardial infarction. Rates of survival free from homograft stenosis and reintervention at 1, 5 and 10 years were 96%, 82% and 75% and 99%, 94% and 91%, respectively. Paediatric patients had worse survival free from homograft stenosis (hazard ratio [HR] 3.50, 95% confidence interval [CI]: 1.56-7.90; P=0.002), although there were no significant differences regarding reintervention (HR: 2.01, 95% CI: 0.52-7.78; P=0.31). Younger age of homograft donor was also a stenosis predictor (HR: 0.97, 95% CI: 0.94-0.99; P=0.046). CONCLUSIONS The probabilities of homograft stenosis and reintervention 10 years after the Ross procedure were 29% and 10%, respectively; only one patient had a reintervention-related death. Younger donor and recipient age were associated with a higher rate of stenosis.
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