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Shih E, Ryan WH, Squiers JJ, Schaffer JM, Harrington KB, Banwait JK, Meidan TG, DiMaio JM, Brinkman WT. Outcomes of the Ross procedure in patients older versus younger than 50 years old. Eur J Cardiothorac Surg 2023; 64:ezad260. [PMID: 37439708 DOI: 10.1093/ejcts/ezad260] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 06/29/2023] [Accepted: 07/12/2023] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVES The Ross procedure is traditionally considered for young adult patients with aortic valve disease. This study compares long-term outcomes of patients undergoing the Ross procedure who are ≥50 and <50-years old. METHODS Data were collected from 225 patients undergoing Ross procedure at a single centre from 1994 to 2019. Patients were categorized into younger (<50-years old; n = 156) and older (≥50-years old; n = 69) cohorts. Baseline demographics clinical outcomes were compared. RESULTS The mean age was 36 ± 8.1 and 55 ± 4.2 years in the younger and older cohort, respectively. Both groups were predominantly male (58.5% vs 69.6%; P = 0.59). The younger group had a higher rate of aortic insufficiency (51% vs 26.1%; P < 0.01), and bicuspid aortic valve (81.4% vs 58.0%; P < 0.01). Aortic stenosis was more prevalent in the older cohort (25.6% vs 58.0%; P < 0.01). Operative mortality was acceptable in both groups (1.3% vs 4.3%; P = 0.15). Survival up to 10 years was not statistically different between 2 groups (96.2% vs 91.3% P = 0.16), whereas survival up to 15 years for younger patients was significantly higher (94.9% vs 85.5%; P = 0.03). After non-cardiac related deaths were excluded, survival up to 15 years (98.7% vs 91.3%; P = 0.02) was significantly lower than younger patients. In both groups, survival after the Ross procedure was similar to the age- and sex-matched US population. CONCLUSIONS Survival up to 10 years after Ross procedure were similar, but up to 15 years was significantly higher in younger patients. The Ross procedure restored patients from both groups to expected survival. Our results suggest that at experienced centres, the Ross procedure is a safe and reasonable option for patients who are 50 years and older.
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Affiliation(s)
- Emily Shih
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital-Plano, Plano, TX, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - William H Ryan
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital-Plano, Plano, TX, USA
| | - John J Squiers
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital-Plano, Plano, TX, USA
| | - Justin M Schaffer
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital-Plano, Plano, TX, USA
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital-Plano, Plano, TX, USA
| | | | - Talia G Meidan
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - J Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital-Plano, Plano, TX, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - William T Brinkman
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital-Plano, Plano, TX, USA
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Marquetand C, Aboud A, Hasfurther M, Göttmann J, Bahlmann E, Busch-Tilge C, Tilge P, Ivannikova M, Ensminger S, Stierle U, Reil GH, Reil JC. New insights into the hemodynamics of pulmonary homograft patients under stress echocardiography: The contribution of pressure recovery. Echocardiography 2023; 40:1058-1067. [PMID: 37638407 DOI: 10.1111/echo.15675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/13/2023] [Accepted: 08/10/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND The importance of pulmonary artery pressure recovery (PR) in patients with Ross procedures in whom a homograft substitutes the resected pulmonary valve, is unknown. The aim of the study was to evaluate the occurrence and extent of PR in the pulmonary artery in 65 asymptomatic patients with pulmonary homograft after Ross surgery during rest and exercise. METHODS Stress echocardiography was performed in 65 pulmonary homograft patients and 31 controls with native pulmonary valves up to 75 W. Right ventricular systolic pressure (RVSP), transvalvular flow, mean pressure gradient (Pmean ), valve resistance, and RV stroke work were determined in the exercise (max. 75 W) and recovery phases in increments of 25 W each. RESULTS Pulmonary homografts demonstrated significantly elevated Pmean compared to controls at all stages. When considering pressure recovery (absolute and relative PR at rest 3.8 ± 1.8 mm Hg, 42.6 ± 7.2%, respectively) and transvalvular energy loss (EL; at rest 4.5 ± 4.3 mm Hg) the homograft hemodynamics reached the level of controls. In a subgroup of patients with tricuspid regurgitation, resting RVSP was the same in homograft patients and controls (21.3 ± 6.1 vs. 20.4 ± 6.3, p = .62), despite significant different Pmax values. CONCLUSIONS Ross patients with pulmonary homograft showed systematically increased hemodynamic parameters compared to normal pulmonary valves. These differences were abolished when PR was considered for homograft patients. The equality of RVSP values at rest in both groups shows non-invasive evidence for PR in the pulmonary system after homograft implantation. Therefore, PR appears to be an important measure in calculating the actual hemodynamics in pulmonary homografts.
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Affiliation(s)
- Christoph Marquetand
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Anas Aboud
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Maria Hasfurther
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Göttmann
- Department of Analysis and Modeling of Complex Data, Johannes Gutenberg University, Mainz, Germany
| | - Edda Bahlmann
- Department of Cardiology, Asklepios Kliniken St. Georg, Hamburg, Germany
| | - Claudia Busch-Tilge
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Patric Tilge
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Maria Ivannikova
- Klinik für allgemeine und interventionelle Kardiologie, HDZ-NRW, Bad Oeynhausen, Germany
| | - Stephan Ensminger
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich Stierle
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Gert-Hinrich Reil
- Universitätsklinik für Innere Medizin I, Kardiologie, Klinikum Oldenburg, Oldenburg, Germany
| | - Jan-Christian Reil
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- Klinik für allgemeine und interventionelle Kardiologie, HDZ-NRW, Bad Oeynhausen, Germany
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Holst T, Petersen J, Friedrich S, Waschki B, Sinning C, Rybczynski M, Reichenspurner H, Girdauskas E. Physical and Mental Recovery after Aortic Valve Surgery in Non-Elderly Patients: Native Valve-Preserving Surgery vs. Prosthetic Valve Replacement. J Cardiovasc Dev Dis 2023; 10:jcdd10040138. [PMID: 37103017 PMCID: PMC10146276 DOI: 10.3390/jcdd10040138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/28/2023] Open
Abstract
Background: Exercise capacity and patient-reported outcomes are increasingly considered crucial following aortic valve (AV) surgery in non-elderly adults. We aimed to prospectively evaluate the effect of native valve preservation compared with prosthetic valve replacement. Methods: From October 2017 to August 2020, 100 consecutive non-elderly patients undergoing surgery for severe AV disease were included. Exercise capacity and patient-reported outcomes were evaluated upon admission, and 3 months and 1 year postoperatively. Results: In total, 72 patients underwent native valve-preserving procedures (AV repair or Ross procedure, NV group), and 28 patients, prosthetic valve replacement (PV group). Native valve preservation was associated with an increased risk of reoperation (weighted hazard ratio: 10.57 (95% CI: 1.24-90.01), p = 0.031). The estimated average treatment effect on six-minute walking distance in NV patients at 1 year was positive, but not significant (35.64 m; 95% CI: -17.03-88.30, adj. p = 0.554). The postoperative physical and mental quality of life was comparable in both groups. Peak oxygen consumption and work rate were better at all assessment time points in NV patients. Marked longitudinal improvements in walking distance (NV, +47 m (adj. p < 0.001); PV, +25 m (adj. p = 0.004)) and physical (NV, +7 points (adj. p = 0.023); PV, +10 points (adj. p = 0.005)) and mental quality of life (NV, +7 points (adj. p < 0.001); PV, +5 points (adj. p = 0.058)) from the preoperative period to the 1-year follow-up were observed. At 1 year, there was a tendency of more NV patients reaching reference values of walking distance. Conclusions: Despite the increased risk of reoperation, physical and mental performance markedly improved after native valve-preserving surgery and was comparable to that after prosthetic aortic valve replacement.
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Affiliation(s)
- Theresa Holst
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 42, 20246 Hamburg, Germany
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Johannes Petersen
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 42, 20246 Hamburg, Germany
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Universitätstraße 14, 86159 Augsburg, Germany
| | - Benjamin Waschki
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 42, 20246 Hamburg, Germany
- Department of Internal Medicine, Itzehoe Hospital, Robert-Koch-Straße 2, 25524 Itzehoe, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 42, 20246 Hamburg, Germany
| | - Meike Rybczynski
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 42, 20246 Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 42, 20246 Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 42, 20246 Hamburg, Germany
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Stenglinstraße 2, 86156 Augsburg, Germany
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Bergeron A, Hertig V, Villeneuve L, Sirois MG, Demers P, El-Hamamsy I, Calderone A. Structural dysregulation of the pulmonary autograft was associated with a greater density of p16 INK4A-vascular smooth muscle cells. Cardiovasc Pathol 2023; 63:107512. [PMID: 36529416 DOI: 10.1016/j.carpath.2022.107512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
The present study tested the hypothesis that a senescent phenotype of vascular smooth muscle cells (VSMCs) may represent the seminal event linked to maladaptive pulmonary autograft remodeling of a small number of patients that underwent the Ross procedure. The diameter of the pulmonary autograft (47±4 mm) of three male patients was significantly greater compared to the pulmonary artery (26±1 mm) excised from bicuspid aortic valve (BAV) patients. The pulmonary autograft was associated with a neointimal region and the adjacent medial region was significantly thinner compared to the pulmonary artery of BAV patients. Structural dysregulation was evident as elastin content of the medial region was significantly reduced in the pulmonary autograft compared to the pulmonary artery of BAV patients. By contrast, collagen content of the medial region of the pulmonary autograft and the pulmonary artery of BAV patients was not significantly different. Reduced medial elastin content of the pulmonary autograft was associated with increased protein levels of matrix metalloproteinase-9. The latter phenotype was not attributed to a robust inflammatory response as the percentage of Mac-2(+)-infiltrating monocytes/macrophages was similar between groups. A senescent phenotype was identified as protein levels of the cell cycle inhibitor p27kip1 were upregulated and the density of p16INK4A/non-muscle myosin IIB(+)-VSMCs was significantly greater in the pulmonary autograft compared to the pulmonary artery of BAV patients. Thus, senescent VSMCs may represent the predominant cellular source of increased matrix metalloproteinase-9 protein expression translating to maladaptive pulmonary autograft remodeling characterized by elastin degradation, medial thinning and neointimal formation.
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Affiliation(s)
- Alexandre Bergeron
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Vanessa Hertig
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Louis Villeneuve
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Martin G Sirois
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Pharmacology & Physiology, Université de Montréal, Quebec, Montreal, Canada
| | - Philippe Demers
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery, Université de Montréal, Montreal, Quebec Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Angelino Calderone
- Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; Department of Pharmacology & Physiology, Université de Montréal, Quebec, Montreal, Canada.
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Tohme S, Jiang S, Farooqi K, Crystal MA, Blitzer D, Ferrari G, Bacha E, Kalfa D. Ross Procedure in Neonate and Infant Populations: A Meta-Analysis Review. World J Pediatr Congenit Heart Surg 2022; 13:759-769. [DOI: 10.1177/21501351221119494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Scarlett Tohme
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Shangqing Jiang
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Kanwal Farooqi
- Division of Pediatric Cardiology, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Matthew A Crystal
- Division of Pediatric Cardiology, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - David Blitzer
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Giovanni Ferrari
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Emile Bacha
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - David Kalfa
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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Shih E, Brinkman WT, Harrington KB, Squiers JJ, Rahimighazikalayeh G, DiMaio JM, Ryan WH. Outcomes of Redo Operations after Ross procedure. J Thorac Cardiovasc Surg 2022; 165:1803-1812.e2. [PMID: 36028359 DOI: 10.1016/j.jtcvs.2022.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/29/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Ross procedure is not commonly performed, owing to the procedural complexity and the risk of autograft and/or homograft reoperation. This study examined outcomes of patients undergoing Ross reinterventions at a dedicated Ross center. METHODS We retrospectively reviewed 225 consecutive patients who underwent a Ross procedure between 1994 and 2019. Index and redo operation characteristics and outcomes were compared between patients with and those without redo operations. Multivariate analysis was used to identify independent predictors of Ross-related reinterventions. Survival was estimated with Kaplan-Meier analysis. RESULTS Sixty-six patients (29.3%) required redo Ross surgery, 41 patients (18.2%) underwent autograft reoperation only, 8 patients (3.6%) had a homograft reintervention, and 17 patients (7.6%) had both autograft and homograft reoperations (12 as a combined procedure and 5 as sequential procedures). The mean time to reintervention was 11 ± 6 years for autograft reoperations and 12 ± 7 years for homograft reoperations. Patients who underwent Ross-related reinterventions were younger (mean, 38 ± 11 years vs 43 ± 11 years; P < .01) and had a higher rate of New York Heart Association class III/IV (56% vs 38%; P = .02) at the index Ross procedure. Most patients undergoing autograft reintervention had aortic insufficiency and/or aneurysm (98.2%; 57 of 58). The primary reason for homograft reintervention was pulmonary stenosis (92%; 23 of 25). The operative mortality of Ross reintervention was 1.5% (1 of 66). Survival at 15 years was similar in patients who required a redo operation and those who did not (91.2% vs 93.9%; P = .23). CONCLUSIONS Ross reinterventions can be performed safely and maintain patients at the normal life expectancy restored by the index Ross procedure up to 15 years at experienced centers.
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Affiliation(s)
- Emily Shih
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex; Baylor Scott and White Research Institute, Dallas, Tex.
| | - William T Brinkman
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - John J Squiers
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | | | - J Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex; Baylor Scott and White Research Institute, Dallas, Tex
| | - William H Ryan
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
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Hage A, Hage F, Valdis M, Guo L, Chu MWA. The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease. Ann Cardiothorac Surg 2021; 10:454-462. [PMID: 34422557 DOI: 10.21037/acs-2021-rp-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
While aortic valve repair remains the ideal intervention to restore normal valvular function, the optimal aortic valve substitute for patients with a non-repairable aortic valve remains an ongoing subject for debate. In particular, younger patients with a non-repairable valve represent a unique challenge because of their active lifestyle and long life expectancy, which carries a higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike prosthetic or homograft aortic valve replacement (AVR), provides an expected survival equivalent to that of the age and gender-matched general population. Contemporary data has shown that the Ross procedure can be performed safely in centers with expertise, and is associated with improved valvular durability, hemodynamics and quality of life.
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Affiliation(s)
- Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Fadi Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Matthew Valdis
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Linrui Guo
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
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8
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Moroi MK, Bacha EA, Kalfa DM. The Ross procedure in children: a systematic review. Ann Cardiothorac Surg 2021; 10:420-432. [PMID: 34422554 DOI: 10.21037/acs-2020-rp-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/10/2021] [Indexed: 12/20/2022]
Abstract
Background The Ross procedure involves autograft transplantation of the native pulmonary valve into the aortic position and reconstruction of the right ventricular outflow tract (RVOT) with a homograft. The operation offers the advantages of a native valve with excellent hemodynamic performance, the avoidance of anticoagulation, and growth potential. Conversely, the operation is technically demanding and imposes the risk of turning single-valve disease into double-valve disease. This systematic review reports outcomes of pediatric patients undergoing the Ross procedure. Methods An electronic search identified studies reporting outcomes on pediatric patients (mean age <18 years, max age <21 years) undergoing the Ross procedure. Long-term outcomes, including early mortality, late mortality, sudden unexpected unexplained death, reoperation due to failure of the pulmonary autograft or RVOT reconstruction, thromboembolic events, bleeding events, and endocarditis-related complications, were evaluated. Results Upon review of 2,035 publications, 30 studies and 3,156 pediatric patients were included. Patients had a median age of 9.5 years and median follow-up period of 5.7 years. Early mortality rates varied from 0.0 to 17.0% and were increased in the neonatal population. Late mortality rates were much lower (0.04-1.83%/year). Reoperation due to pulmonary autograft failure occurred at rates of 0.37-2.81%/year and reoperation due to RVOT reconstruction failure was required at rates of 0.34-4.76%/year. Thromboembolic, bleeding, and endocarditis events were reported to occur at rates of 0.00-0.58, 0.00-0.39, and 0.00-1.68%/year, respectively. Conclusions The Ross operation offers a durable aortic valve replacement (AVR) option in the pediatric population that offers favorable survival, excellent hemodynamics, growth potential, decreased risk of complications, and avoidance of anticoagulation. Larger multi-institutional registries focusing on pediatric patients are necessary to provide more robust evidence to further support use of the Ross procedure in this population.
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Affiliation(s)
- Morgan K Moroi
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Emile A Bacha
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - David M Kalfa
- Section of Congenital and Pediatric Cardiothoracic Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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9
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Emmott A, Hertig V, Bergeron A, Villeneuve L, Lefebvre L, Leask RL, Calderone A, El-Hamamsy I. Distinct Expression of Nonmuscle Myosin IIB in Pulmonary Arteries of Patients With Aortic Stenosis vs Insufficiency Undergoing a Ross Procedure. Can J Cardiol 2020; 37:47-56. [PMID: 32544488 DOI: 10.1016/j.cjca.2020.02.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clinical studies have revealed a greater risk of pulmonary autograft dilation after the Ross procedure in patients with preoperative aortic insufficiency (AI). The present study examined whether the morphologic, biomechanical, and cellular properties of the pulmonary artery (PA) from patients with AI were phenotypically different compared with patients diagnosed with aortic stenosis (AS). METHODS PA segments were harvested from patients undergoing the Ross procedure for AS (n = 16) and AI (n = 6). Preoperative aortic annulus was significantly larger (P < 0.05) in patients with AI (28.5 ± 1.8 mm) vs AS (22.8 ± 1.2 mm). Morphologic, biomechanical, and cellular phenotypes of the PA were analyzed. RESULTS Collagen and elastin content in the media of the PA wall were similar in patients with AS and AI. Elastic modulus and energy loss of the PA were not significantly different between the groups. In the media of the PA, expression of a panel of vascular smooth muscle cell-specific proteins were similar in patients with AS and AI. In contrast, nonmuscle myosin IIB protein levels in the PA of AS patients were significantly higher compared with AI patients, and immunofluorescence identified staining in α-smooth muscle actin-positive vascular smooth muscle cells. CONCLUSIONS Despite similar morphological and biomechanical properties, the disparate expression of nonmuscle myosin IIB protein distinguishes the PA of patients with AI from patients with AS. The biological role in vascular smooth muscle cells and the potential contribution of nonmuscle myosin IIB to pulmonary autograft dilation in a subset of AI patients after the Ross procedure remain to be determined.
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Affiliation(s)
- Alexander Emmott
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Chemical Engineering, McGill University, Montréal, Québec, Canada
| | - Vanessa Hertig
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada
| | - Alexandre Bergeron
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada
| | - Louis Villeneuve
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada
| | - Laurence Lefebvre
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Richard L Leask
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Pharmacology and Physiology, Université de Montréal, Montréal, Québec, Canada
| | - Angelino Calderone
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Pharmacology and Physiology, Université de Montréal, Montréal, Québec, Canada
| | - Ismail El-Hamamsy
- Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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Varrica A, Caldaroni F, Saitto G, Satriano A, Lo Rito M, Chiarello C, Ranucci M, Frigiola A, Giamberti A. Outcomes and Quality of Life After Ross Reintervention: Would You Make the Same Choice Again? Ann Thorac Surg 2019; 110:214-220. [PMID: 31770502 DOI: 10.1016/j.athoracsur.2019.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/27/2019] [Accepted: 10/02/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The Ross procedure was introduced as a long-term if not definitive solution for aortic pathology. However, the rate of reoperation is not negligible. METHODS This single-center prospective study assessed the general outcome of Ross reoperation and patients' perceived quality of life compared with 2 control groups (Ross non-reoperation and mechanical aortic valve replacement). Patient's preference regarding the choice between mechanical aortic valve and Ross procedure was investigated in a subgroup that could theoretically have been directed to either of the 2 procedures. RESULTS Between 2005 and 2017, 64 consecutive patients underwent reoperation after Ross. Median age was 31 years. Median freedom from reoperation after the Ross procedure was 136 months. An autograft reoperation was required in 49, and 25 had homograft failure. No in-hospital death was recorded. Mean follow-up was 77 months (range, 6-164 months). Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. The Ross reoperation group showed a lower score involving psychological concerns compared with the other groups. In the reoperated-on patients group, 52 had adequate aortic annulus dimensions to receive a prosthetic valve instead of a Ross procedure. When asked whether they would make the same choice, only 31% confirmed the preference. CONCLUSIONS Reoperations after Ross procedure have low mortality and morbidity. Long-term follow-up showed a high quality of life, even after reoperations. However, owing to psychological concerns after the redo operation, when choosing a Ross procedure, it is our duty to thoroughly explain to patients that a high level of disillusion is predictable in case of reoperations.
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Affiliation(s)
- Alessandro Varrica
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese, Italy.
| | - Federica Caldaroni
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese, Italy
| | - Guglielmo Saitto
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese, Italy
| | - Angela Satriano
- Anesthesia and Intensive Care Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Mauro Lo Rito
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese, Italy
| | - Carmelina Chiarello
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese, Italy
| | - Marco Ranucci
- Anesthesia and Intensive Care Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Alessandro Frigiola
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese, Italy
| | - Alessandro Giamberti
- Congenital Cardiac Surgery Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese, Italy
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Mazine A, Rocha RV, El-Hamamsy I, Ouzounian M, Yanagawa B, Bhatt DL, Verma S, Friedrich JO. Ross Procedure vs Mechanical Aortic Valve Replacement in Adults: A Systematic Review and Meta-analysis. JAMA Cardiol 2019; 3:978-987. [PMID: 30326489 DOI: 10.1001/jamacardio.2018.2946] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The ideal aortic valve substitute in young and middle-aged adults remains unknown. Objective To compare long-term outcomes between the Ross procedure and mechanical aortic valve replacement in adults. Data Sources The Ovid versions of MEDLINE and EMBASE classic (January 1, 1967, to April 26, 2018; search performed on April 27, 2018) were screened for relevant studies using the following text word search in the title or abstract: ("Ross" OR "autograft") AND ("aortic" OR "mechanical"). Study Selection All randomized clinical trials and observational studies comparing the Ross procedure to the use of mechanical prostheses in adults undergoing aortic valve replacement were included. Studies were included if they reported any of the prespecified primary or secondary outcomes. Studies were excluded if no clinical outcomes were reported or if data were published only as an abstract. Citations were screened in duplicate by 2 of the authors, and disagreements regarding inclusion were reconciled via consensus. Data Extraction and Synthesis This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. Data were independently abstracted by 3 reviewers and pooled using a random-effects model. Main Outcomes and Measures The prespecified primary outcome was all-cause mortality. Results The search identified 2919 reports, of which 18 studies (3516 patients) met inclusion criteria, including 1 randomized clinical trial and 17 observational studies, with a median average follow-up of 5.8 (interquartile range, 3.4-9.2) years. Analysis of the primary outcome showed a 46% lower all-cause mortality in patients undergoing the Ross procedure compared with mechanical aortic valve replacement (incidence rate ratio [IRR], 0.54; 95% CI, 0.35-0.82; P = .004; I2 = 28%). The Ross procedure was also associated with lower rates of stroke (IRR, 0.26; 95% CI, 0.09-0.80; P = .02; I2 = 8%) and major bleeding (IRR, 0.17; 95% CI, 0.07-0.40; P < .001; I2 = 0%) but higher rates of reintervention (IRR, 1.76; 95% CI, 1.16-2.65; P = .007; I2 = 0%). Conclusions and Relevance Data from primarily observational studies suggest that the Ross procedure is associated with lower all-cause mortality compared with mechanical aortic valve replacement. These findings highlight the need for a large, prospective randomized clinical trial comparing long-term outcomes between these 2 interventions.
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo V Rocha
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Maral Ouzounian
- Department of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Department of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Subodh Verma
- Department of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Department of Critical Care Medicine, St Michael's Hospital, Toronto, Ontario, Canada
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Ibrahim M, Spelde AE, Carter TI, Patel PA, Desai N. The Ross Operation in the Adult: What, Why, and When? J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2017.12.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Valve performance classification in 630 subcoronary Ross patients over 22 years. J Thorac Cardiovasc Surg 2018; 156:79-86.e2. [PMID: 29606322 DOI: 10.1016/j.jtcvs.2018.03.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/30/2018] [Accepted: 03/05/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To define the function of the "Ross valves" and its clinical meaning in a practical valve performance classification as part of the outcome analysis. METHODS From 1994 to 2017, 630 consecutive patients underwent the subcoronary Ross procedure at our institution. The valve performance classification combines hemodynamics, symptoms, and management criteria. Median follow-up was 12.5 years (maximum 22.3 years, 7404 patient-years, 99.4% completeness). RESULTS The mean age of the patients was 44.7 ± 11.9 years. Hospital deaths was 0.3% (n = 2). Twenty years after the operation survival was 73.1% (95% confidence interval [CI], 65.4%-81.6%) and statistically not different from the age- and gender-matched general population; freedom from reoperation was 85.9% (95% CI, 80.2%-92.0%; 0.6% per patient-year), 89.8% (95% CI, 84.3%-95.7%) for autograft, and 91.0% (95% CI, 86.3%-96.0%) for homograft. Preoperative annulus diameter, aortic regurgitation, annulus reinforcement, sinotubular junction reinforcement, and bicuspid aortic valve type were no significant risk factors for reoperation. At 20 years the probability of a patient being in valve performance class I to IV was 5%, 74%, 19%, and 1%, respectively. Time to reoperation was not different in bicuspid and tricuspid aortic valves; preoperative aortic stenosis tended to have better outcome of autograft function. CONCLUSIONS These up to 22 years data show that the subcoronary Ross procedure continues to provide an excellent tissue aortic valve replacement. The suggested valve performance classification emerged as a practical concept for outcome analysis with the probability of 79% being in the favorable class I or II at 20 years.
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