Outcomes of reoperations after Ross procedure

Redo aortic root surgery post-Ross procedure

Background

Despite numerous advantages of the Ross procedure, it presents a risk of late autograft and right ventricular outflow tract conduit failure. This study aimed to analyze the outcomes of autograft dysfunction reoperations using autograft-sparing and root replacement techniques.

Methods

Between 2015 and 2023, 49 patients underwent redo root surgery in our institution. Autograft valve-sparing procedures (VSP) were performed in 20 cases and the Bentall procedure (BP) in 29 patients. The short and long-term clinical outcomes along with echocardiographic results of VSP and BP were investigated.

Results

Overall early mortality rate was 2.0% with no significant difference between the groups. Severe autograft valve insufficiency at the time of redo (OR 4.07, P = 0.03) and patient age (OR 1.07, P = 0.04) were associated with a valve replacement procedure instead of VSP. The median follow-up duration was 34 months. No late deaths occurred in either group. Freedom from VSP failure and aortic prosthesis dysfunction were 93.8% and 94.1% in the VSP and BP groups, respectively. No reoperations were necessary in either group.

Conclusion

Redo aortic root surgery can be safely performed in patients with autograft failure. Both root replacement and autograft valve-sparing procedures demonstrated acceptable results at mid-term follow-up. Early redo surgery pre-empting severe aortic insufficiency increases the likelihood of preservation of the dilated autograft valve.

Systematic review and meta-analysis of time-to-event long-term outcomes following the Ross procedure

Background

The optimal aortic valve substitute for non-elderly adults remains controversial. Recently, considerable data on the Ross procedure have accumulated. This study aimed to analyze long-term outcomes following the Ross procedure from the current literature using a meta-analysis of time-to-event outcomes.

Methods

A literature search was performed with MEDLINE, EMBASE, Cochrane Library, Web of Science, and Google Scholar through June 2022; studies reporting clinical outcomes of the Ross procedure beyond 20 years were included for analysis. The outcomes of interest were late survival and freedom from surgical or percutaneous reintervention of the autograft or right ventricular outflow tract (RVOT).

Results

Six studies, including 4,910 patients (3,601 males), were identified and analyzed. Survival rate at 5, 10, 15, and 20 years was 99.9%±0.1%, 97.6%±0.5%, 94.3%±0.9%, and 87.4%±1.9%. Freedom from autograft reintervention at 5, 10, 15, and 20 years was 97.7%±0.5%, 95.3%±0.7%, 91.4%±1.2%, 84.8%±2.5%. Freedom from RVOT reintervention was 99.0%±0.3%, 99.0%±0.3%, 97.5%±0.7%, 93.3%±1.8%. Freedom from any valve reintervention (either autograft or RVOT) at 5, 10, 15, and 20 years was 95.8%±0.6%, 92.6%±0.9%, 88.5%±1.2%, 80.8%±2.5%.

Conclusions

This meta-analysis demonstrated that the Ross procedure was confirmed to provide excellent survival despite the need for reintervention of autograft or RVOT in approximately 20% of patients at 20 years.

Autograft reoperations after the Ross procedure

OBJECTIVES

After a Ross procedure, autograft failure can occur. At reoperation, repair of the autograft preserves the advantages of the Ross procedure. The aim of this retrospective study was to assess mid-term results after reoperation of a failed autograft.

METHODS

Between 1997 and 2022, 30 consecutive patients (83% male; age 41 ± 11 years) underwent autograft reintervention between 60 days and 24 years (median 10 years) after a Ross procedure. The initial technique varied, full-root replacement (n = 25) being the most frequent. The indication for reoperation was isolated autograft regurgitation (n = 7), root dilatation (>43 mm) with (n = 17) or without (n = 2) autograft regurgitation, mixed dysfunction (n = 2) and endocarditis (n = 2). In 4 instances, the valve was replaced by valve (n = 1) or combined valve and root replacement (n = 3). Valve-sparing procedures consisted of isolated valve repair (n = 7) or root replacement (n = 19), and tubular aortic replacement. Cusp repair was performed in all but 2. Mean follow-up was 5.4 ± 6 years (35 days to 24 years).

RESULTS

Mean cross-clamp and perfusion times were 74 ± 26 and 132 ± 64 min. There were 2 perioperative deaths (7%; both valve replacement) and 2 patients died late (32 days to 1.2 years postoperatively). Freedom from cardiac death at 10 years was 96% after valve repair and 50% after replacement. Two patients required reoperation (1.68 and 16 years) following repair. One underwent valve replacement for cusp perforation, the other, root remodelling for dilatation. Freedom from autograft reintervention at 15 years was 95%.

CONCLUSIONS

Autograft reoperations after the Ross procedure can be performed as valve-sparing operations in the majority of cases. With valve-sparing, long-term survival and freedom from reoperation are excellent.

Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era

BACKGROUND

The Ross procedure has several advantages, but the need for reintervention is inevitable. The aim of this study was to examine the complexity and outcomes of reoperation after the Ross procedure.

METHODS

Retrospective chart review was performed of patients with a prior Ross procedure who underwent reoperation at our institution from September 1991 to January 2021. Demographic, echocardiographic, surgical, and perioperative data were collected. Descriptive statistical and regression analyses were performed.

RESULTS

A total of 105 patients underwent a reoperation at Mayo Clinic after the initial Ross procedure performed at our institution (n = 16; 16.2%) or elsewhere (n = 83; 83.8%). Mean age at the Ross procedure was 27 ± 17 years, and mean age at reoperation at our institution was 37 ± 19 years. Indications for surgical procedure varied, but 64% had autograft regurgitation as 1 of their indications for reoperation. Autograft interventions were performed in 78 patients (74.2%). Pulmonary valve or conduit replacement was performed in 56 patients (53.3%). Double root replacement was performed in 11 patients (10.5%). Aortic reconstruction was performed in 37 patients (38.4%). There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%). Patients with ejection fraction <30% on preoperative echocardiography had shorter duration between the Ross procedure and subsequent reoperation (P = .03).

CONCLUSIONS

Reoperations after the Ross procedure are performed for a wide range of indications, with most due to autograft dysfunction. The number of early deaths is not low. Reoperation after the Ross procedure should be advised before left ventricular systolic dysfunction.

The Ross Procedure in Adolescence and Beyond: Are There Still Contraindications?

The Ross procedure is an excellent operation to treat children and adults with aortic valve disease. Compared to prosthetic aortic valve replacement, it provides important clinical benefits in terms of survival, hemodynamics, freedom from valve-related complications, and durability, especially in women of childbearing age. However, the Ross procedure is a longer and technically more challenging operation. As a result, the choice of procedure should be driven by patient anatomy and clinical characteristics. This highlights the importance of concentrating care in Ross reference centers where surgical expertise and experience are present to ensure patient safety and long-term effectiveness of the operation. This manuscript reviews the major and relative contraindications to the Ross procedure.

Ross Procedure Versus Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Network Meta-Analysis

Background The Ross operation appears to restore normal survival in young and middle-aged adults with aortic valve disease. However, there are limited data comparing it with conventional aortic valve replacement. Herein, we compared outcomes of the Ross procedure with mechanical and bioprosthetic aortic valve replacement (M-AVR and B-AVR, respectively). Methods and Results MEDLINE and EMBASE were searched through March 2022 to identify randomized controlled trials and propensity score-matched studies that investigated outcomes of patients aged ≥16 years undergoing the Ross procedure, M-AVR, or B-AVR. The systematic literature search identified 2 randomized controlled trials and 8 propensity score-matched studies involving a total of 4812 patients (Ross: n=1991; M-AVR: n=2019; and B-AVR: n=802). All-cause mortality was significantly lower in the Ross procedure group compared with M-AVR (hazard ratio [HR] [95% CI], 0.58 [0.35-0.97]; P=0.035) and B-AVR (HR [95% CI], 0.32 [0.18-0.59]; P<0.001) groups. The reintervention rate was lower after the Ross procedure and M-AVR compared with B-AVR, whereas it was higher after the Ross procedure compared with M-AVR. Major bleeding rate was lower after the Ross procedure compared with M-AVR. Long-term stroke rate was lower following the Ross procedure compared with M-AVR and B-AVR. The rate of endocarditis was also lower after the Ross procedure compared with B-AVR. Conclusions Improved long-term outcomes of the Ross procedure are demonstrated compared with conventional M-AVR and B-AVR options. These results highlight a need to enhance the recognition of the Ross procedure and revisit current guidelines on the optimal valve substitute for young and middle-aged patients.

Outcomes of Redo Operations after Ross procedure

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.

Supporting the Ross procedure: preserving root physiology while mitigating autograft dilatation

PURPOSE OF REVIEW

The purpose of this article is to describe the optimized approach to nonrepairable aortic valve disease in young adults with a Ross procedure, while preserving the dynamic physiology of the aortic root.

RECENT FINDINGS

As the techniques for supporting pulmonary autografts continue to be refined, and the applicability of the Ross procedure continues to expand, an assessment of the various techniques based on aortic root physiology is warranted. Semi-resorbable scaffolds show promise in ovine models for improving the Ross procedure. Recent long-term outcomes for the Dacron inclusion technique in comparison to more physiologic methods of support emphasize the importance of balancing the prevention of early dilatation with the preservation of root haemodynamics. As this review will synthesize, the dynamic physiology of the root may be preserved even in patients at a higher risk of autograft dilatation.

SUMMARY

The favourable long-term outcomes of the Ross procedure can be partly attributed to the ability of the autograft to restore dynamism to the neoaortic root. Patient-specific modifications that respect root physiology can tailor the Ross procedure to address each patient's risk factors for early dilatation and late failure. As such, the Ross procedure should be recognized as an increasingly favourable solution for a wide spectrum of nonpreservable aortic valve disease in young adults.