Congenital: Aortic Valve
Aortic valve repair versus the Ross procedure in children

Read at the 103rd Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, California, May 6-9, 2023.
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Abstract

Background

Aortic valve repair and the Ross procedure are widely used in children; however, it is unclear which provides the best outcomes.

Methods

Patients who underwent primary aortic valve surgery from 1980 to 2018 were included. Propensity score matching was performed to adjust for baseline differences.

Results

Of 415 children, 82.7% (343/415) underwent repair and 17.3% (72/415) underwent the Ross procedure. At 15 years, survival was higher for aortic valve repair (93.9% ± 1.8% vs 80.9% ± 6.4%, P = .04); freedom from reoperation (45.7% ± 4.9% vs 48.5% ± 9.0%, P = .29) did not differ, and freedom from aortic valve reoperation was higher in the Ross procedure group (45.7% ± 4.9% vs 70.7% ± 8.0%, P < .001). When analyzed by quality of repair, acceptable repair provided the highest survival (P = .01). Acceptable repair and the Ross procedure had similar freedom from reoperation at 15 years, whereas suboptimal repair performed worse (acceptable: 54.9% ± 6.7%; Ross procedure: 48.5% ± 9.0%; suboptimal: 27.0% ± 7.7%, P < .001). Acceptable repair and the Ross procedure had similar freedom from aortic valve reoperation at 15 years, whereas suboptimal repair showed worse results (acceptable: 54.9 ± 6.7; Ross procedure: 70.7% ± 8.0%; suboptimal: 27.0% ± 7.7%, P < .001). Propensity score matching paired 66 patients who underwent the Ross procedure with 198 patients who underwent repair. At 15 years, repair was associated with better survival (98.0% ± 1.2% vs 78.5% ± 7.2%, P = .03), whereas freedom from reoperation was similar (42.6% ± 7.6% vs 50.7% ± 9.8%, P = .50). However, the Ross procedure was associated with higher freedom from aortic valve reoperation (42.6% ± 7.6% vs 72.3% ± 8.5%, P = .002).

Conclusions

Primary aortic valve repair was associated with better survival than the Ross procedure, whereas overall freedom from reoperation was similar. When an acceptable intraoperative result was achieved, outcomes of repair were favorable. However, when the intraoperative result of repair was suboptimal, the Ross procedure showed better results.

Section snippets

Patients

All patients who underwent aortic valve repair or the Ross procedure as their initial aortic valve operation at the Royal Children's Hospital, Melbourne, between 1980 and 2018 were included in the study. Patients who had prior aortic valve surgery were excluded (Figure 1). Ethics approval was granted by the Royal Children's Hospital Human Research Ethics Committee (HREC 35205 on 21/9/2015).

Definitions

Early death was defined as death within 30 days of surgery or before discharge from hospital. Acceptable

Baseline Data

A total of 415 patients were included in the study, of whom 82.7% (343/415) underwent aortic valve repair and 17.3% (72/415) underwent the Ross procedure. Baseline demographics are summarized in Table 1. Patients undergoing repair were younger (P < .001), had lower weight (P < .001), were more likely to have unicuspid valves (P = .04), were less likely to have bicuspid valves (P < .01), and were more likely to have aortic stenosis (P < .001).

Additional concomitant surgery in the repair group

Discussion

Pediatric aortic valve surgery presents a formidable challenge due to the need to achieve a durable result while preserving growth potential. The 2 surgical strategies that currently meet these requirements are aortic valve repair and the Ross procedure. Recently, the Ozaki technique has been proposed as an alternative, but early results do not appear comparable to repair or the Ross procedure.9,10 The optimal initial surgical strategy is not clear. Our institutional preference is to perform

Conclusions

In children, primary aortic valve repair was associated with better survival than the Ross procedure, whereas freedom from cardiac reoperation was similar. In infants, aortic valve repair was associated with better survival. In older children, repair and the Ross procedure showed overall similar outcomes. When an acceptable intraoperative result could be achieved, outcomes of repair were favorable. However, when the repair was suboptimal, the Ross procedure performed significantly better.

References (21)

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