Long-term outcomes following the Ross procedure in neonates and infants: A multi-institutional analysis

OBJECTIVES

For neonates and infants with aortic valve pathology, the Ross procedure historically has been associated with high rates of morbidity and mortality. Data regarding long-term durability are lacking.

METHODS

The international, multi-institutional Ross Collaborative included 6 tertiary care centers. Infants who underwent a Ross operation between 1996 and 2016 (allowing a minimum 5 years of follow-up) were retrospectively identified. Serial echocardiograms were examined to study evolution in neoaortic size and function.

RESULTS

Primary diagnoses for the 133 patients (n = 30 neonates) included isolated aortic stenosis (14%, n = 19), Shone complex (14%, n = 19), and aortic stenosis plus other (excluding Shone complex; n = 95, 71%), including arch obstruction (n = 55), left ventricular hypoplasia (n = 9), and mitral disease (moderate or greater stenosis or regurgitation, n = 31). At the time of the Ross procedure, median age was 96 days (interquartile range, 36-186), and median weight was 4.4 kg (3.6-6.5). In-hospital mortality occurred in 13 of 133 patients (10%) (4/30 [13%] neonates). Postdischarge mortality occurred in 10 of 120 patients (8%) at a median of 298 days post-Ross. Post-Ross neoaortic dilatation occurred, peaking at 4 to 5 SDs above normal at 2 to 3 years before returning to near-baseline z-score at a median follow-up of 11.5 [6.4-17.4] years. Autograft/left ventricular outflow tract reintervention was required in 5 of 120 patients (4%) at a median of 10.3 [4.1-12.8] years. Freedom from moderate or greater neoaortic regurgitation was 86% at 15 years.

CONCLUSIONS

Neonates and infants experience excellent postdischarge survival and long-term freedom from autograft reintervention and aortic regurgitation after the Ross. Neoaortic dilatation normalizes in this population in the long-term. Increased consideration should be given to Ross in neonates and infants with aortic valve disease.

The Ross-Konno Procedure With or Without Mitral Valve Surgery: A Systematic Review With Individual Data Pooling

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.

Innovation in surgical treatment of hypertrophic obstructive cardiomyopathy in children

Hypertrophic cardiomyopathy is the second most common cardiomyopathy affecting children and adolescents and is the main cause of sudden death of young athletes. The natural prognosis of children with severe hypertrophic obstructive cardiomyopathy is not optimistic, and it is not uncommon for children with hypertrophic obstructive cardiomyopathy who do not respond to medication. Surgical treatment is often the only solution. Conventional surgical methods in the past include classic or modified extended Morrow operation, classic or modified Konno operation, and Ross-Konno operation. In recent years, with the development of minimally invasive surgery, various minimally invasive surgical methods have emerged endlessly. Because the incision of minimally invasive cardiac surgery is significantly smaller than that of traditional surgery, it causes less trauma, recovers quickly after surgery, and has the advantage of no difference in surgical effect compared with traditional median sternotomy. Tally endoscopic transmitral myectomy, RTM, minimally right thoracotomy, and other surgical methods have achieved encouraging results in adults and some older children with hypertrophic obstructive cardiomyopathy. The appearance of transapical beating-heart septectomy has brought the treatment of hypertrophic obstructive cardiomyopathy from the era of cardiopulmonary bypass and cardiac arrest to a new era of minimally invasive beating-heart surgery. In the past, there were few articles about the treatment of children with hypertrophic obstructive cardiomyopathy. This article reviewed the new progress and prognosis of surgical treatment of children with hypertrophic obstructive cardiomyopathy at home and abroad.

Ross Procedure in Neonate and Infant Populations: A Meta-Analysis Review

Objective

This study aims to perform a meta-analysis of early and late outcomes of the Ross/Ross-Konno procedures in neonates/infants.

Methods

A meta-analysis was performed in accordance with PRISMA guidelines. We used Ovid versions of MEDLINE/PubMed for relevant studies and included those that reported Ross/Ross-Konno operations in neonates/infants and at least one of the predetermined clinical outcomes. I2 and double arcsine methods assessed the heterogeneity between pooled estimates. We used a random-effect model to account for heterogeneity with MetaXL. We calculated point estimates of a pooled estimates along with its 95% CI.

Results

587 neonate/infant patients were included with median age of 87.5 days old. The follow-up range was five days to 23 years. Early mortality reported in 25 studies with pooled estimates of 18.3% (95% CI: 13.6%-23.5%). Estimates ranged from 0% to 50% with relatively substantial heterogeneity ( P = .01, I2 = 48.6%). Late mortality reported in 22 studies with pooled incidence of 9.7% (95% CI: 5.9%-14.3%). Estimates ranged from 0% to 53% with relatively substantial heterogeneity ( P = .01, I2 = 46.1%). Autograft reintervention reported in 18 studies with pooled estimate of 19.2% (95% CI: 7.3%-34.5%). Estimates ranged from 0% to 81.8% with high heterogeneity ( P < .001, I2 = 90.5%). Right ventricle-to-pulmonary artery conduit reintervention reported in 16 studies with pooled estimates of 32.0% (95% CI: 20.9%-44.12%). Estimates ranged from 0% to 92.3% with high heterogeneity ( P < .001, I2 = 75.9%).

Conclusions

The data suggest that the Ross/Ross-Konno procedure in neonates/infants still carries significant risk of early/late mortality and autograft/conduit reintervention. The high variability of results among centers confirms the need for surgical expertise and good patient selection. Prospective multicenter studies are warranted to investigate the rate of autograft reintervention and the impact on long-term survival in this specific population.

Subcoronary Ross/Ross-Konno operation in children and young adults: initial single-centre experience

OBJECTIVES

We sought to evaluate the outcome after modified subcoronary Ross/Ross-Konno operation in children and young adults.

METHODS

Between January 2013 and January 2019, a total of 50 patients with median age of 6.3 years (range 0.02-36.5 years, 58% males), including 10 infants (20%), received modified subcoronary Ross/Ross-Konno operation at our institution. Survival, morbidity, reinterventions, aortic valve function and aortic root dimensions were analysed.

RESULTS

At a median follow-up of 31.2 months (range 14.4-51 months), there were 1 early death and 1 late death, both in the infant group. The overall survival at 5 years after the operation was 95%. Two patients needed aortic valve replacement, 11 and 15 months after their Ross operation. At 5 years, freedoms from reoperation on the autograft and on the right ventricle to pulmonary artery conduit were 94% and 97%, respectively. Freedom from aortic valve regurgitation greater than mild was 97% at 5 years. Median dimensions of the aortic root at all levels remained in normal range at last visit. Forty-four patients (95%) were in New York Heart Association class I with normal left ventricular function.

CONCLUSIONS

The initial experience with the subcoronary Ross/Ross-Konno operation in children and young adults showed excellent outcome. The mortality and morbidity among infants remain significant. The described technique is reproducible and might be advantageous in situations when prosthetic supporting techniques interfere with somatic growth.

Ross Operation in Neonates: A Meta-analysis

BACKGROUND

The Ross operation is the preferred treatment for aortic valve replacement in children. However previous studies indicate that outcomes in neonates are poor. This meta-analysis examines the pooled outcomes of the Ross operation in neonates.

METHODS

Four major databases (PubMed/MEDLINE, EMBASE, Scopus, and ScienceDirect) were searched from inception until May 1, 2020 for studies describing outcomes of the Ross operation in neonates. The primary outcome was early mortality, and secondary outcomes were late mortality and mechanical support. Random-effects models were used to account for possible heterogeneity between studies, and continuity corrections were used to include zero total event trials.

RESULTS

Eighteen studies comprising outcomes data on 181 neonates were included in the analysis. Meta-analysis showed a pooled early mortality rate of 24% (95% confidence interval, 12%-38%; I² = 52%, P for heterogeneity = .01). Meta-regression analysis showed that more recently published studies reported significantly worse early mortality (P = .03). The pooled incidence of postoperative mechanical support was 15% (95% confidence interval, 5%-28%; I² = 28%, P for heterogeneity = .22). No evidence of publication bias was found according to Egger's test (bias coefficient = 0.21, P = .57).

CONCLUSIONS

The neonatal Ross operation carries a high early mortality rate. The treatment of unrepairable aortic valves in neonates remains an unsolved problem in congenital cardiac surgery.