Fate of the Aortic Root Late After Ross Operation

Abstract

Background-The Ross operation is an alternative to mechanical aortic valve replacement in the young. Early dilatation of the pulmonary autograft root exposed to the systemic circulation has been reported. To define the prevalence of, risk factors for, and consequences of late autograft dilatation, outcome in all consecutive patients operated since May 1994 was reviewed. Methods and Results-Ninety one patients, 77 males and 14 females, with at least 1 year of follow-up underwent cross-sectional clinical and echocardiographic examination. Age at operation was 27Ϯ10 years (range 6 to 49), and the indication was aortic regurgitation in 54 (59%) patients and bicuspid valve was present in 62 (68%). End-points of the study were freedom from autograft dilatation (root diameter Ͼ4 cm or 0.21 cm/m 2 ), from (moderate) autograft regurgitation and from reoperation. Follow-up (4.0Ϯ1.9, range 1 to 8 years) autograft root diameters were anulus, 29Ϯ4 mm (18 -39); sinus of Valsalva, 38Ϯ7 mm (24 -53); sinotubular junction, 37Ϯ6 mm (23-54); and ascending aorta, 37Ϯ5 mm (27-54). Late autograft dilatation was identified in 31 (34%) patients and regurgitation in 13 (14%), 7 of whom had autograft dilatation. At 7 years, freedom from dilatation was 42Ϯ8%, freedom from regurgitation was 75Ϯ8%, and freedom from reoperation was 85Ϯ10%. Cox proportional hazard analysis identified younger age (Pϭ0.05), preoperative sinus of Valsalva (Pϭ0.02), root replacement technique (Pϭ0.03), and absence of pericardial buttressing (Pϭ0.04) as predictive of autograft dilatation, whereas female sex (Pϭ0.002), follow-up sinus of Valsalva (Pϭ0.003), and sinotubular junction diameter (Pϭ0.02) as predictive of autograft regurgitation. Conclusions-Autograft dilatation is common late after the Ross procedure, particularly in younger patients, in those with preoperative aortic aneurysm, and those having root replacement without support of anulus and sinotubular junction. Bicuspid aortic valve is not a risk factor. Significant autograft valve dysfunction affects a minority of patients, but it is more prevalent in those with autograft dilatation.

Thoracic and Abdominal Aortic Aneurysms

“…In one series of 91 patients, the incidence of pulmonary autograft root dilatation was 61% at 5 years among those with a prior aortic aneurysm, compared with 27% among those with no prior aortic aneurysm (ie, those who had surgery for aortic valve disease only). 24 When full aortic root/valve replacement is necessary, another alternative to a composite graft is the use of cryopreserved aortic allografts (cadaveric aortic root and proximal ascending aorta). However, after the procedure, late structural valvular deterioration does occur and may lead to subsequent reoperation.…”

Outcomes and Associated Risk Factors for Aortic Valve Replacement in 160 Children

“…32 Other authors have reported progressive dilation of the autograft with differential prevalence, depending on the definition used (generally 4.0 cm or greater), the method used for detection, and the duration of follow-up. 11 Predisposing factors favoring dilation have included anatomic mismatch between the pulmonary and aortic root and a complete aortic root replacement technique without pericardial buttressing of the ascending aorta and annulus. 11,31,33 …”

“…The Ross operation (use of the pulmonary valve as an autograft) introduced in 1967 10 has emerged as an attractive alternative, but concerns persist about the fate of the neoaortic valve, the potential for development of neoaortic valve insufficiency, and the lack of consistent long-term outcome data. [11][12][13][14] In addition, autograft use often necessitates repeated interventions for right ventricular outflow tract obstruction. 3,12 In addition to prosthesis failure and reoperation, children are simultaneously at an increased risk of death after AVR.…”

Diagnosis and Treatment of Bicuspid Aortic Valve Disease

“…However, recent studies show that reoperation requirement in 10 years is 25% in autografts and 14% in allografts (25). This complication is more common in patients who are young and in patients with aortic dilatation before the surgery (26). To prevent posterior dilatation in patients who underwent Ross procedure, using inclusion techniques, homograft and allograft wraps are suggested.…”