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

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.

The Ross Procedure in Children and Infants: A Systematic Review With Pooled Analyses

“…Overall, 25 observational studies with a total of 2737 patients were included. 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 By design, all included studies had a ROBINS I score in the low or moderate risk of bias category ( Supplemental Table S1 ).

Figure 1 Flow chart of the literature search.

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“… 16 , 17 Consistently, a recent study in neonates (<30 days of age) reported high levels of early (24%) and late (43%) mortality after the Ross procedure. 3 Although outcomes have improved over time, 18 several studies including an analysis using the Society for Thoracic Surgeons Congenital Heart Disease Database 18 and a recent meta-analysis 19 in children reported significant associations between low-volume centres (defined as <4 cases/y in the Society for Thoracic Surgeons study) and higher mortality, particularly among neonates. 16 , 17 …”

“… 25 A higher autograft reintervention point prevalence rate of 19.2% was reported in a recent meta-analysis that included studies of the Ross-Konno procedure and had a follow-up that ranged from 5 days to 23 years. 19 Results have been inconsistent across studies as to whether the Ross procedure is associated with fewer or more reinterventions than other options for aortic valve replacement. 22 , 26 Reintervention rates did not favour the Ross procedure in Alsoufi et al’s study.…”

A midterm follow-up study of the application of a confluent aortic valve neocuspidization technique with pericardium in children

“…AVR still has many limitations in children such as rapid deterioration ( 3 , 4 ) in bioprosthetic valves, high risk of anticoagulation-related complications ( 5 , 6 ) in mechanical valves as well as size mismatch in young patients with small annuluses ( 7 ). The Ross procedure is a good option for young children but it is not widely applied in developing countries due to relatively high mortality, lack of valved conduit, and risk of impacting both semilunar valves ( 8 , 9 ). Partial heart transplantation contributes a new approach to solve the problem, allowing annular growth, but the risks from immunosuppression remain concern ( 10 ).…”

Invited Commentary: What Is the Significance of the Konno Incision in Pediatric Ross Procedures?

“…Unfortunately, many of these complex patients require aortic valve and LVOT intervention in the neonatal and infant period when the procedural risk of a Ross-Konno is highest. 2 There is however substantial heterogeneity in Ross procedure outcomes in this age range 6 and more recently excellent outcomes have been demonstrated in the contemporary era. 7 Despite potentially higher procedural risk, long-term pulmonary autograft longevity may be optimized by performing the Ross procedure in the neonatal and infant age range as the pulmonary root remains adapted to systemic pressures at this stage.…”