Incidence of and Risk Factors for Pulmonary Autograft Dilation After Ross Aortic Valve Replacement

doi:10.1016/j.athoracsur.2006.12.066

The Annals of Thoracic Surgery

Volume 83, Issue 5, May 2007, Pages 1781-1789

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.

https://doi.org/10.1016/j.athoracsur.2006.12.066 Get rights and content

Background

The Ross procedure is an alternative to mechanical aortic valve replacement in the young. Early dilation of the pulmonary autograft root exposed to the systemic circulation has been reported. The aim of our study is to define the prevalence, risk factors, and consequences of autograft dilation. All consecutive adult and pediatric patients who underwent Ross procedure at our institution were retrospectively reviewed for autograft dilation.

Methods

Between 1993 and 2005, 170 patients (mean age, 24.9 ± 15.5 years; range, 1 month to 61 years) underwent Ross aortic valve replacement: 48% were younger than 19 years old. Eighty-seven additional procedures were performed in 58 patients (34%) at the time of the Ross procedure. End points of the study were freedom from autograft dilation (z value more than +2.0), autograft dysfunction, autograft reoperation, and autograft replacement.

Results

There were 2 early and 1 late deaths during a mean follow-up of 5.1 ± 3.0 years (range, 1 month to 12 years). Actuarial survival at 10 years was 98%. Autograft dilation was identified in 31 patients (19%). Regurgitation (>2+) was identified in 12 patients (7%); all 12 had autograft dilation. At 10 years, freedom from autograft dilation was 82%, freedom from autograft dysfunction was 92%, freedom from reoperation on autograft was 92%, and freedom from autograft replacement was 96%. Cox proportional hazard analysis identified preoperative aortic annulus dilation (z value more than +2.0; p = 0.004), younger age (p = 0.05), time of surgery (before 2001; p = 0.002), and male sex (p = 0.01) as predictive of autograft dilation, whereas preoperative ascending aorta diameter (p = 0.01), male sex (p = 0.03), and postoperative systemic hypertension (p = 0.05) were predictive of autograft dysfunction.

Conclusions

Significant autograft dilation is not common after the Ross procedure. Significant autograft dysfunction affects a minority of patients, but it is more prevalent in those with autograft dilation.

Section snippets

Material and Methods

Between June 1993 and December 2005, 170 consecutive patients underwent Ross AVR at the Indiana University Hospitals including the James W. Riley Hospital for Children in Indianapolis. This study has been approved, and the Indiana University Institutional Review Board waived the need to obtain patient consent for this study. Of these patients, 6 (4%) were younger than 1 year of age, 76 (45%) were between 1 and 19 years of age, and 88 (51%) were older than 19 years of age. Mean age at operation

Survival

There were two early (1.2%) and 1 late (0.6%) deaths. A 48-year-old patient with severe bicuspid aortic stenosis and micronodular cirrhosis with history of hepatitis C underwent Ross AVR and coronary artery bypass grafting of the right coronary artery; this patient postoperatively had a cardiac arrest and died 4 days later of multisystem organ failure secondary to liver and pulmonary failure, hepatorenal syndrome, and sepsis. One neonate with critical aortic stenosis underwent an emergent

Comment

Our study confirms previous reports documenting the safety of the Ross procedure in selected children and young adults and a low prevalence of postoperative thromboembolic complications and endocarditis [2, 5, 6, 7, 11, 12]. Long-term survival is excellent [2, 5, 6, 7, 11, 12, 13, 19]. All 3 deaths in this series (2 early and 1 late) were in patients with complex associated problems. Our survival for children and adults out to 13 years (mean, 5.5 years) is 98% and compares favorably to the

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Cited by (44)

Ross Versus Non-Ross Aortic Valve Replacement in Children: A 22-Year Single Institution Comparison of Outcomes
2016, Annals of Thoracic Surgery
Citation Excerpt :
The difference in rate of endocarditis and bleeding was statistically significant (p < 0.05). The rate of reoperation in the early part of our Ross experience was the largest drawback to the Ross AVR, and that trend has been reported in the literature [1–4]. Autograft or ascending aorta dilation and RVOT stenosis across the pulmonary allograft were equal causes of reintervention in our Ross series, and this has been noted in many early Ross reports [3].
The Ross aortic valve replacement (AVR) has been the AVR of choice for children at our center since 1993. Absence or inadequate quality of the pulmonary valve or, less commonly, family or surgeon preference caused us to select an alternative AVR prosthesis for some children. This review compares the outcomes of 42 children who received a non-Ross AVR with 115 children undergoing Ross root replacement at our institution during the most recent 22 years.
A retrospective chart review of the 42 pediatric non-Ross AVRs was compared with 115 Ross AVRs. The mean age at AVR was 11.0 ± 6.5 years (range, 1 month to 18 years) for the non-Ross and 11.4 ± 5.5 years (range, 6 weeks to 18 years) for the Ross groups. Follow-up was 7.8 ± 6.2 years for the Ross group and 8.7 ± 6.5 years for the non-Ross group. The Ross AVR technique was modified in 2000; these modifications were applied to 72 patients (63%) of the total Ross AVR group.
All-cause early and late mortality of the non-Ross AVR group was 17% compared with 4% for the Ross cohort (p = 0.017). The actuarial survival rate at 20 years for the non-Ross AVR group was 81% compared with 94% for the Ross group (p = 0.018). Reintervention rate was 29% (12/38) in the non-Ross group and 28% (32/115) in the entire Ross group (60% [26/43] before 2000, and 8% [6/72] after 2000). Thromboemboli, bleeding, and endocarditis occurred in 2.4%, 1.4%, and 10% in the non-Ross group compared with 0.9%, 2.6%, and 1.7% in the Ross AVR group (p = 0.46, 0.01, and 0.02), respectively. Patients in the non-Ross group had a significantly higher recurrent or persistent aortic valve gradient (>20 mm Hg) than did patients in the Ross group at most recent follow-up (p < 0.05).
Lower mortality, valve-related complications, and better hemodynamics were seen after the Ross AVR than with other types of AVR prostheses. The Ross AVR remains the treatment of choice for children who have an adequate pulmonary valve. Reoperation for Ross root dilatation, regurgitation, or both (only 6% since our modifications in 2000) has markedly reduced the main drawbacks of this AVR technique. The Ross AVR affords the growing child the advantages of a growing, autologous, viable valve substitute and eliminates the lifelong disadvantages of mechanical and xenograft valves.
Options for aortic valve replacement in children and young adults: "okay, doctor, but which one do you think i should choose?"
2016, Journal of Thoracic and Cardiovascular Surgery
An experimental model of the Ross operation: Development of resorbable reinforcements for pulmonary autografts
2015, Journal of Thoracic and Cardiovascular Surgery
To circumvent the issue of pulmonary autograft (PA) dilation after the Ross procedure, surgical reinforcement strategies have been suggested in clinical or anecdotal series. However, no preclinical large-animal model of the Ross procedure is available, which is needed to enable full comprehension of the pathologic mechanisms and the effectiveness of reinforcement techniques during growth. Our aim was to develop a large-animal model of the Ross operation, to reproduce the clinical scenario in which this procedure might be applied, and allow for development and testing of various devices and techniques to improve PA performance. In addition, we aimed to test the effectiveness of a bioresorbable mesh for PA reinforcement.
An experimental model of transposition of the pulmonary trunk as an autograft in the aortic position has been developed and performed under cardiopulmonary bypass in 20 growing lambs, aged 3 months. The experimental design included: a control group that underwent PA transposition; a group in which the PA was reinforced with an external, synthetic, nonresorbable, polypropylene grid; and a group that received various combinations of resorbable meshes. Animals were followed up during growth for 6 months by angiography and echocardiography and eventually killed for pathologic analysis.
All animals survived the procedure with no complications. The model was easy and reproducible. Resorbable meshes prevented PA dilation and preserved its progressive growth process, aiding histologic remodelling.
We developed an easy and reproducible model of the Ross procedure, allowing for a reliable simulation of the clinical scenario. Resorbable PA reinforcement may represent an interesting option in this context.
Failed autograft after the ross procedure in children: Management and outcome
2014, Annals of Thoracic Surgery
Citation Excerpt :
Reoperation for postoperative (AI) or dilated aortic root or ascending aorta has been reported [6–9, 11, 18–20]. Although relatively low reoperation rates have been reported in the first 5 postoperative years, our experience and that of others indicates that a high percentage of patients develop significant autograft regurgitation and autograft dilation requiring reoperation 5 years or more after Ross AVR [7, 11, 18–20]. In our series, 17 of the 22 reoperations (77%) on the pulmonary autograft were performed more than 5 years postoperatively and as late as 18 years after the initial Ross AVR (Table 3; Fig 1).
Autograft dilatation (AD) and aortic insufficiency (AI) after the Ross procedure are the most common causes of late autograft failure. The purpose of this study was to examine the results of valve-sparing root replacement (modified David) and composite root replacement.
We performed a retrospective review of all children (n = 78) undergoing a Ross procedure at our Center from 1993 to 2011.
Median follow-up was 10 years (1to 18 years). Freedom from autograft reoperation was 94% at 5 years, and 65% at 15 years. Freedom from greater than 2+ autograft AI was 93% at 5 years and 76% at 15 years. Autograft reoperation was necessary in 22 patients, at a median interval of 8.7 years after the original procedure. Indications for reoperation were AI with autograft dilatation in 15 patients, AI without dilatation in 2 patients, and AD without AI in 5 patients. Surgical procedures used at reoperation included valve-sparing root replacement in 14 patients, root replacement either mechanical or biologic valved conduit in 6 patients, and valve replacement in 2 patients. At a mean follow-up of 5.8 years after reoperation, 4 patients from the valve-sparing group underwent second reoperation (valve replacement). Freedom from second autograft reoperation was 71% for patients after a valve sparing procedure and 100% for patients after an aortic valve or root replacement (Bentall procedure) at 5 years.
Autograft valve-sparing root replacement and composite aortic root replacement are effective treatments for aortic root dilation and AI after the Ross procedure. The potential of late autograft insufficiency after valve-sparing root replacement warrants annual follow-up.
Autograft or allograft aortic root replacement in children and young adults with aortic valve disease: A single-center comparison
2012, Annals of Thoracic Surgery
We analyzed the outcome of children and young adults (younger than 40 years) with aortic valve disease who underwent allograft or autograft aortic root replacement (ARR) in our institution and evaluated whether there is a preference for either valve substitute.
One-hundred fifty patients younger than 40 years underwent ARR between January 1990 and July 2011. Forty-four patients, aged 18.8 ± 12.4 years, had ARR with allograft conduit (allograft group), whereas 106 patients, aged 17.9 ± 11 years (p = 0.63), had a Ross ARR during the same period of time (autograft group). Echocardiographic data were reviewed to evaluate valve performance. The 2 groups were similar with respect to age, gender, etiology, and previous and concomitant procedures.
Operative deaths were 3 in the autograft group. There were 6 late deaths in the autograft group and 5 in the allograft group. Survival was 92% and 84% at 5 and 15 years, respectively, in the allograft group versus 93% and 91% in the autograft group (p = 0.42). Freedom from any type of reintervention and from reoperation on aortic valve were similar (autograft, 64% and 72% versus allograft, 66% and 66%; p = not significant) at 15 years. Freedom from explantation were significantly better for Ross patients (autograft, 82% versus allograft, 66%; p = 0.05).
Aortic valve replacement with either the autograft or allograft provides good clinical results in children and young adults during an intermediate duration of observation. Survival early after ARR does not differ depending on the type of prosthesis. In patients with aortic valve disease, autograft and allograft ARR show comparable satisfactory early and long-term results, with the increasing reoperation risk in the second decade after operation remaining a major concern.
Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: An update on the German Dutch Ross Registry
2012, Journal of Thoracic and Cardiovascular Surgery
Reinterventions after the Ross procedure are a concern for patients and treating physicians. The scope of the present report was to provide an update on the reinterventions observed in the large patient population of the German-Dutch Ross Registry.
From 1988 to 2011, 2023 patients (age, 39.05 ± 16.5 years; male patients, 1502; adults, 1642) underwent a Ross procedure in 13 centers. The mean follow-up was 7.1 ± 4.6 years (range, 0-22 years; 13,168 patient-years).
In the adult population, 120 autograft reinterventions in 113 patients (1.03%/patient-year) and 76 homograft reinterventions in 67 patients (0.65%/patient-year) and, in the pediatric population, 14 autograft reinterventions in 13 patients (0.91%/patient-year) and 42 homograft reinterventions in 31 patients (2.72%/patient-year) were observed. Of the autograft and homograft reinterventions, 17.9% and 21.2% were performed because of endocarditis, respectively. The subcoronary technique in the adult population resulted in significantly superior autograft durability (freedom from autograft reintervention: 97% at 10 years and 91% at 12 years; P < .001). The root replacement technique without root reinforcement (hazard ratio, 2.4; 95% confidence interval, 1.4-4.1) and the presence of pure aortic insufficiency preoperatively (hazard ratio, 2.3; 95% confidence interval, 1.5-3.5) were statistically significant predictors for a shorter time to reoperation. The center volume had a significant influence on the long-term results. The freedom from homograft reoperation for the adults and pediatric population was 97% and 87% at 5 years and 93% and 79% at 12 years, respectively (P < .001), with younger recipient and donor age being significant predictors of a shorter time to homograft reoperation.
The autograft principle remains a valid option for young patients requiring aortic valve replacement. The risk of reoperation depends largely on the surgical technique used and the preoperative hemodynamics. Center experience and expertise also influence the long-term results. Adequate endocarditis prophylaxis might further reduce the need for reoperation.

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Original articleCardiovascularIncidence of and Risk Factors for Pulmonary Autograft Dilation After Ross Aortic Valve Replacement

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Survival

Comment

Lancet

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Ann Thorac Surg

Am J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Early results of the Ross procedure in simple and complex left heart disease

Circulation

Original article
Cardiovascular
Incidence of and Risk Factors for Pulmonary Autograft Dilation After Ross Aortic Valve Replacement