Impact of a tailored surgical approach on autograft root dimensions in patients undergoing the Ross procedure for aortic regurgitation†

Abstract

OBJECTIVES The Ross procedure in patients with aortic regurgitation (AR) has been associated with increased autograft dilatation and late reintervention. The aim of this study was to evaluate the impact of a tailored approach aimed at mitigating that risk on early changes in autograft root dimensions following the Ross procedure in patients with AR. METHODS From 2011 to 2018, 241 consecutive patients underwent a Ross procedure with >1 year of follow-up [46 (7) years]. Aortic root dimensions were prospectively measured on serial echocardiograms. Patients with aortic stenosis group (n = 171; 71%) were compared to those with AR or mixed aortic disease (AR group) (n = 70; 29%). Mean length of follow-up was 29 ± 11 months (100% complete). Changes in aortic dimensions were analysed using mixed-effect models. RESULTS At 4 years, mean indexed diameters of the annulus, sinuses of Valsalva and the sinotubular junction in the AR group were 12.3 (0.2) mm/m2, 20.0 (0.4) mm/m2 and 16.3 (0.9) mm/m2, respectively, vs 11.9 (0.2), 18.4 (0.3) and 15.5 (0.5) in the aortic stenosis group. Overall, there were no significant differences in the rates of autograft annulus, sinuses of Valsalva and sinotubular junction dimension changes between the aortic stenosis and AR groups up to 4 years after surgery (P = 0.55, P = 0.12, P = 0.59 and P = 0.48, respectively). CONCLUSIONS Use of a tailored surgical approach, combined with a strict blood pressure control, appears to mitigate clinically significant early dilatation of the autograft root following a Ross procedure in patients with AR. Further follow-up is needed to determine if this will translate into a lower incidence of long-term reintervention.

Ross operation after failure of aortic valve repair

“…The main finding from this study is that the full-root Ross technique with a tailored stabilization approach after previous aortic valve repair is associated with excellent survival and durability (33). In our study, mid-term survival is 98% and is equivalent to that of the age-and gendermatched general population.…”

The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease

“…Recent studies attribute these earlier findings to incomplete stabilization of the aortic root at the index surgery, resulting in autograft dilatation at the level of the annulus, sinuses of Valsalva and sinotubular junction (46)(47)(48)(49). When a tailored approach is employed in a high-volume center to ensure adequate support of the pulmonary autograft, the Ross procedure results in excellent autograft durability (50). On the other hand, the pulmonary homograft, when implanted into the low-pressure pulmonary circulation, is expected to be less vulnerable to structural degeneration (51).…”

“…To mitigate the risk of potential early changes in autograft root dimensions following exposure to systemic pressures and the consequent autograft failure, several groups advocate for the institution of an individualized, tailored approach (50,66). Patients undergoing the Ross procedure for aortic insufficiency and those with a dilated aortic annulus greater than or equal to 27 mm preoperatively are particularly prone to this complication (66).…”

“…Thus, the ideal candidate for the Ross procedure is a patient with a projected life expectancy of >fifteen years, who presents with aortic valve disease (ideally isolated AS), a nondilated aortic annulus (<27 mm) and normal aortic dimensions (44,45,50,66,70) The Ross procedure should also be given particular consideration in female patients of childbearing age contemplating pregnancy, patients with a high level of physical activity and those who have contraindications to or prefer to avoid anticoagulation. Conventional AVR is not well suited to women contemplating a future pregnancy given the major setbacks of both bioprosthetic and mechanical prostheses.…”

“…Several technical refinements have been proposed at each step of the operation to improve its performance and durability (46)(47)(48)50,75,76). At our institution, we routinely try to preserve as much native aortic wall as possible, such as the non-coronary sinus and the bridge of aortic wall between the left/right sinus (Figure 1A), which we later incorporate into the anastomosis with the ascending aorta to provide external support for the pulmonary autograft (Figure 1B).…”