Exercise performance in children and adolescents after the Ross procedure

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

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

Longitudinal Changes in Exercise Capacity in Patients Who Underwent Ross Procedure and Mechanical Aortic Valve Replacement: Does the Type of Surgery Matter?

The surgical options for significant aortic valve disease include either Ross procedure (RP) or aortic valve replacement (AVR). The exercise stress test is routinely performed in these patients to assess the objective functional capacity. This retrospective study was conducted to evaluate the differences and the longitudinal changes of exercise capacity in patients following the RP and AVR for aortic valve disease. This is an IRB approved retrospective study and included patients who had either RP or AVR performed for aortic valve disease and had at least one exercise stress test performed after the surgical procedure. Patients with other congenital heart disease, pacemaker or defibrillators, and those with inadequate data were excluded. Demographic data including age at surgery, type of surgery and type of aortic valve was collected. Data regarding treadmill cardiopulmonary exercise test (CPET) was also collected. A total of 47 patients met inclusion criteria and were equally represented in each group, i.e. RP [n = 23, 73.9% male, age at surgery 11.2 (4.5-15.9) years] vs. AVR [n = 24, 88% mechanical AVR, 60.9% male, age at surgery 15.1 (12.8-19.4) years]. There was a significant decline in predicted oxygen consumption (%VO₂) at time of first post-operative CPET in patients after AVR compared to RP (79 vs. 88%, p = 0.048) over a similar accrued median interval follow-up (4.6 vs. 6.2 years, p = 0.2). The longitudinal follow-up analysis of following AVR (n = 11, 54.5% male, median inter-test duration of 5 years) showed significant decline in peak exercise capacity or VO₂ (34.2 vs. 26.2 vs., p = 0.006). In contrast, after RP (n = 12 patients [58.3% male, median inter-test duration 7.1 of years], exercise capacity and other key parameters remained preserved. In this small sentinel study, we report a better initial exercise capacity among patients after RP compared to AVR over an intermediate follow-up. During longitudinal follow-up in a subset of patients, exercise capacity remained preserved amongst the RP group while it further declined in the AVR group.

Exercise stress echocardiography after childhood Ross surgery: functional outcome in 26 patients from a single institution

Adult studies suggest a better functional outcome after aortic valve replacement with a pulmonary autograft compared with mechanical or homograft valves. Little is known about functional results after Ross surgery in growing children. This study reports formal exercise stress echocardiographic data from 26 pediatric Ross patients. A retrospective cohort study analyzed stress echocardiographic data of patients who underwent Ross surgery as a child (<17 years old). All patients were operated by a single surgeon and underwent a Bruce protocol stress echocardiogram on the treadmill. Twenty-six patients (4 girls) were 9.3 ± 5.0 years at surgery and 14.9 ± 3.5 years (range 6.6-19.7 years) at follow-up. Mean follow-up was 5.4 ± 3.7 years (median 4.2). All were asymptomatic. The exercise time was normal in 87% of cases at 12.8 ± 2.5 min. On stress echocardiography, the mean right-ventricular outflow tract (RVOT) gradient increased from 38 ± 22 mmHg at rest to 82 ± 33 mmHg after exercise, but this did not correlate with exercise times. Stress echocardiography is useful in evaluating patients after childhood Ross surgery for aortic valve disease. In this pediatric cohort, most patients achieved normal exercise capacity. The presence of mild or moderate RVOT obstruction had no significant impact on exercise capacity.

Decreased aerobic capacity 4 years after aortic valve replacement in male patients operated upon for chronic aortic regurgitation

Exercise testing is underutilized in patients with valve disease. We have previously found a low physical work capacity in patients with aortic regurgitation 6 months after aortic valve replacement (AVR). The aim of this study was to evaluate aerobic capacity in patients 4 years after AVR, to study how their peak oxygen uptake (peakVO₂) had changed postoperatively over a longer period of time. Twenty-one patients (all men, 52 ± 13 years) who had previously undergone cardiopulmonary exercise testing (CPET) pre- and 6 months postoperatively underwent maximal exercise testing 49 ± 15 months postoperatively using an electrically braked bicycle ergometer. Breathing gases were analysed and the patients' physical fitness levels categorized according to Åstrand's and Wasserman's classifications. Mean peakVO₂ was 22·8 ± 5·1 ml × kg⁻¹ × min⁻¹ at the 49-month follow-up, which was lower than at the 6-month follow-up (25·6 ± 5·8 ml × kg⁻¹ × min⁻¹, P = 0·001). All but one patient presented with a physical fitness level below average using Åstrand's classification, while 13 patients had a low physical capacity according to Wasserman's classification. A significant decrease in peakVO₂ was observed from six to 49 months postoperatively, and the decrease was larger than expected from the increased age of the patients. CPET could be helpful in timing aortic valve surgery and for the evaluation of need of physical activity as part of a rehabilitation programme.

Exercise function of children with congenital aortic stenosis following aortic valvuloplasty during early infancy

OBJECTIVES

The objectives of this study were to characterize the exercise function of patients treated with balloon aortic valvuloplasty at

BACKGROUND

Balloon aortic valvuloplasty is the primary therapy for neonatal aortic stenosis (AS). Residual and/or acquired abnormalities of left heart structure and function may adversely affect exercise capacity. Methods. We prospectively recruited patients >6 years old with a history of neonatal AS to undergo exercise testing.

RESULTS

We enrolled 30 patients (median age 13.1 years) who underwent balloon aortic valvuloplasty at a median age of 12 days. At time of exercise testing, the median maximum Doppler AS gradient was 34 mm Hg (0-70 mm Hg); 11 patients had moderate or severe aortic regurgitation. All patients were asymptomatic. Overall, peak oxygen consumption (VO(2)) was below normal (87 +/- 18% predicted; P < .001), and was severely depressed (

CONCLUSION

Although exercise function is preserved in most patients with a history of AS treated in early infancy, a subset have markedly reduced peak VO(2), usually because of inability to increase stroke volume.

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Key Words

• aortic stenosis
• exercise
• balloon aortic valvuloplasty

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MESH Headings

• Adolescent
• Aortic Valve/physiology
• Aortic Valve/surgery
• Aortic Valve Stenosis/congenital
• Aortic Valve Stenosis/physiopathology
• Aortic Valve Stenosis/surgery
• Catheterization
• Child
• Exercise
• Exercise Test
• Female
• Follow-Up Studies
• Heart Rate/physiology
• Humans
• Infant
• Infant, Newborn
• Male
• Oxygen Consumption/physiology
• Predictive Value of Tests
• Prospective Studies
• Stroke Volume/physiology
• Young Adult

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Grants

• T32 HL007572 NHLBI NIH HHS

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Affiliation(s)

Alaina K Kipps Department of Cardiology, Children's Hospital, Boston, Mass 02115, USA.
Doff B McElhinney
Janet Kane
Jonathan Rhodes

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Quality-of-life concerns differ among patients, parents, and medical providers in children and adolescents with congenital and acquired heart disease

OBJECTIVES

Mortality rates in pediatric patients with heart disease have decreased dramatically in recent decades, resulting in an increasing number of survivors with morbidities that impact quality of life. The purpose of this study was to assess and compare how heart disease affects the quality of life of the pediatric cardiac patient from the perspectives of the patient, parent, and health care provider.

METHOD

Individual focus groups were conducted with children (8-12 years of age) with heart disease, adolescents (13-18 years of age) with heart disease, parents of children with heart disease, parents of adolescents with heart disease, and health care providers of pediatric patients with heart disease. A structured focus group technique was used to develop a list of potential items that might affect quality of life. Participants chose the 5 most important items from the list. These items were then categorized into preidentified dimensions (physical, psychological, social, school, and other). The percentages of the total votes for all items were calculated and distributions of responses across dimensions within group and within dimension across groups were reported and compared qualitatively.

RESULTS

Patient and parent groups identified similar items as important. Providers identified different items. The physical limitation item received the largest percentage of total votes in all groups (9%-20%). Analysis across dimension revealed that those items related to the physical dimension received the highest percentage of total votes among all groups (30.2%-51.2%). Analysis within dimension revealed that patients endorsed items in the physical dimension more frequently than parents or providers. Within the psychological dimension, the children selected the fewest items relative to all other groups (7.2% vs 21.3%-37.8%), whereas health care providers endorsed these items more frequently than patients or parents (child or parent of child groups 7.2%-21.3% vs health care provider group 28.8%; adolescent or parent of adolescent groups 29.6% vs health care provider group 37.8%). Differences were noted between the child and adolescent groups in the psychological (child versus adolescent: 7.2% vs 29.6%) and school (child versus adolescent: 11.2% vs 2.1%) dimensions.

CONCLUSIONS

Patients and parents generally agreed on how heart disease affects the quality of life of children and adolescents, whereas health care providers had a different opinion.

Is the Ross procedure as good as we thought it would be?

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.