The long term results of the Ross procedure: The importance of candidate selection

doi:10.1016/j.ijcard.2020.07.009

International Journal of Cardiology

Volume 320, 1 December 2020, Pages 35-41

https://doi.org/10.1016/j.ijcard.2020.07.009 Get rights and content

Highlights

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The use of the Ross procedure represents <1% of all aortic valve replacements.
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Freedom from all re-operation was 89% after 10 years and 83% after 15 years.
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Freedom from redo surgery for AV was 90% after 10 years and 81% after 15 years.
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Rheumatic valves and aortic root diameter > 15 mm/m2 have worse outcome.
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A pulmonary fresh preserved homograft seems to perform better on the long term.

Abstract

The Ross procedure has been considered in children as an optimal surgical procedure due to potential growth of the aortic annulus, lack of anticoagulation requirement, very low morbidity rate and excellent survival.

Five-hundred-thirty-six (366 male, mean age 29.4 ± 11.1 years) underwent Ross procedure between 1990 and 2016 and had complete clinical and echocardiographic follow-up. Mean follow-up was 16.3 ± 4.9 years. Patients were divided in 2 groups according to age at surgery. Group 1 consisted of 320 (60%) patients less than 18 years old (223 male, mean age at surgery of 9.5 ± 5.6 years). Group 2 consisted of 216 (40%) patients older than 18 years of age (143 male, mean age at surgery of 26.3 ± 8.2 years).

One-hundred-thirty (24%) patients had a redo procedure or surgery. Freedom from all re-operation and or percutaneous reintervention on either the aortic and pulmonary valves was 99% after 1 year, 94% after 5 years, 89% after 10 years, 83% after 15 years and 78% after 20 years. Freedom from redo surgery for AV 99% after 1 year, 94% after 5 years, 90% after 10 years, 81% after 15 years and 80% after 20 years. Freedom from redo surgery for PV was 100% after 1 year, 95% after 5 years, 89% after 10 years, 78% after 15 years and 76% after 20 years.

The ideal candidate for Ross operation is a patient with congenital aetiology and an aortic root diameter ≤ 15 mm/m². A pulmonary fresh preserved homograft seems to perform better on the long term.

Section snippets

Background

The ultimate goal of a valve replacement is to achieve a normal haemodynamic condition; therefore, the ideal substitute for the aortic valve should have excellent haemodynamic profile, long durability, no risk of bleeding or stroke, excellent long term outcomes and survival. Following these principles Donald Ross firstly described in 1950s a cardiac surgery where a diseased aortic valve (AV) is replaced with the person's own pulmonary valve (PV). A pulmonary or aortic graft is then used to

Patient population

Between 1990 and 2016 more than 600 patients underwent RP in our Institution. Of these, 536 (366 male, mean age 29.4 ± 11.1 years) had complete clinical and echocardiographic follow-up. They were divided in 2 groups according to age at surgery.

Group 1 consisted of 320 (60%) patients, < 18 years old (223 male, mean age at surgery of 9.5 ± 5.6 years, mean age at follow-up of 23.7 ± 4.5 years). Of these 99 (31%) had rheumatic aetiology, 213 (66%) had congenital aetiology and 8 (3%) patients were

Aetiology, previous procedures and concomitant surgery

As expected, a rheumatic aetiology was more common in patients ≥18 years of age, while a congenital aetiology was more common in younger. Aortic stenosis was the most common preoperative diagnosis in younger patients.

One hundred twenty-nine (24%) patients had previous cardiac procedures or surgery. All operative details of previous surgery are shown in Table 3 (e-component).

Ninth-five (18%) patients had a concomitant surgical procedure. All details are shown in Table 4 (e-component).

Clinical, echocardiographic and follow-up data

Fourteen

General considerations

The present study on RP outcome is a large, single-centre cohort with one of the longest follow up to the best of our knowledge. Our study confirms that the RP is associated with an excellent survival in both adults and children and it has an extremely low early mortality in experienced centres [[26], [27], [28], [29], [30], [31], [32]]. In our centre early mortality was 1.4%, with a very low late death rate of 1.2%.

Conclusion

Based on our analysis, a rheumatic aetiology, aortic regurgitation, and an aortic root diameter (>15 mm/m²) are associated with a poor outcome. Our study also suggests that the preference of a pulmonary cryopreserved homograft will probably perform better on long term.

Technical expertise is required to ensure optimal benefits and enhanced durability for the patients [[49], [50]]. As with any complex procedure a certain volume of RP is needed to develop expertise.

We do believe that a better

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Cited by (14)

Outcomes of redo operations after the Ross procedure
2023, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
This study confirms many of our previous findings, as well as those of others. The 29% rate of Ross-related reoperation in our cohort is comparable to the percentage reported by a large series of 536 patients reported by Pergola and colleagues.19 Our average time to reoperation of approximately 11 years is consistent with other reports.12,20
The Ross procedure is not commonly performed, owing to the procedural complexity and the risk of autograft and/or homograft reoperation. This study examined outcomes of patients undergoing Ross reinterventions at a dedicated Ross center.
We retrospectively reviewed 225 consecutive patients who underwent a Ross procedure between 1994 and 2019. Index and redo operation characteristics and outcomes were compared between patients with and those without redo operations. Multivariate analysis was used to identify independent predictors of Ross-related reinterventions. Survival was estimated with Kaplan–Meier analysis.
Sixty-six patients (29.3%) required redo Ross surgery, 41 patients (18.2%) underwent autograft reoperation only, 8 patients (3.6%) had a homograft reintervention, and 17 patients (7.6%) had both autograft and homograft reoperations (12 as a combined procedure and 5 as sequential procedures). The mean time to reintervention was 11 ± 6 years for autograft reoperations and 12 ± 7 years for homograft reoperations. Patients who underwent Ross-related reinterventions were younger (mean, 38 ± 11 years vs 43 ± 11 years; P < .01) and had a higher rate of New York Heart Association class III/IV (56% vs 38%; P = .02) at the index Ross procedure. Most patients undergoing autograft reintervention had aortic insufficiency and/or aneurysm (98.2%; 57 of 58). The primary reason for homograft reintervention was pulmonary stenosis (92%; 23 of 25). The operative mortality of Ross reintervention was 1.5% (1 of 66). Survival at 15 years was similar in patients who required a redo operation and those who did not (91.2% vs 93.9%; P = .23).
Ross reinterventions can be performed safely and maintain patients at the normal life expectancy restored by the index Ross procedure up to 15 years at experienced centers.
Survival and freedom from reoperation after the Ross procedure in a Russian adult population: A single-center experience
2022, JTCVS Open
Citation Excerpt :
The reoperation due to the pulmonary autograft dysfunction is the Achilles' heel of the Ross procedure. The rate of autograft reinterventions differs between studies, and common indications for reoperation include the neoaortic root dilatation, infective endocarditis, technical failures, and others.6,8,11,12 In the current study, the freedom from reoperation for the autograft was 89.1% (95% CI, 81.2%-97.8%) at 11 years.
To evaluate our 12-year experience with the Ross procedure in adults.
A retrospective analysis of 215 cases of the Ross procedure was performed. The mean age of the patients was 36 ± 11.1 years, and the male to female ratio was 75% to 25%, respectively. The pulmonary autograft was placed into the aortic position using the full-root replacement technique and its modified versions. The right ventricular outflow tract was reconstructed using a pulmonary homograft in all cases.
The 30-day mortality after the operation was 0.9% (2 patients). The median duration of follow-up was 6.1 years (interquartile range, 6.5 years) and was complete in 86% of cases. The survival at 12 years was 94.7% and was comparable with the survival rate of the general population matched for age and sex. At the end of the follow-up, freedom from reoperation due to pulmonary autograft and homograft dysfunction was 89.1% and 99%, respectively.
In our series, the Ross procedure resulted in low early mortality and excellent survival in adults. The long-term survival was not statistically different from the survival of the general population. The pulmonary homograft offered an excellent durability and freedom from reoperation.
Unlocking insights in bicuspid aortic valve management in adult patients: the vital role of cardiac imaging
2024, Monaldi Archives for Chest Disease
Unveiling the gothic aortic arch and cardiac mechanics: insights from young patients after arterial switch operation for d-transposition of the great arteries
2024, Monaldi Archives for Chest Disease
The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement
2024, Journal of Clinical Medicine
Echocardiography in Simple Congenital Heart Diseases: Guiding Adult Patient Management
2023, Journal of Cardiovascular Echography

View all citing articles on Scopus

¹: Present addresses: Department of Cardiology, Padua University Hospital, Italy.

²: Present addresses: Department of Paediatric Cardiology, Padua University Hospital, Italy

View full text

The long term results of the Ross procedure: The importance of candidate selection

Highlights

Abstract

Section snippets

Background

Patient population

Aetiology, previous procedures and concomitant surgery

Clinical, echocardiographic and follow-up data

General considerations

Conclusion

J. Thorac. Cardiovasc. Surg.

J. Am. Coll. Cardiol.

J Thorac Cardiovasc Surg.

Lancet.

Lancet.

J. Thorac. Cardiovasc. Surg.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Ann. Thorac. Surg.

J. Thorac. Cardiovasc. Surg.

Ann. Thorac. Surg.

J. Am. Coll. Cardiol.

J. Thorac. Cardiovasc. Surg.

J. Am. Coll. Cardiol.

J. Thorac. Cardiovasc. Surg.

J. Am. Coll. Cardiol.

Ann. Thorac. Surg.

Ann. Thorac. Surg.

The pulmonary autograft for aortic valve replacement

The Mini-Ross-Konno procedure

Eur. J. Cardiothorac. Surg.

Mechanical valves versus the Ross procedure for aortic valve replacement in children: propensity-adjusted comparison of long-term outcomes

J. Thorac. Cardiovasc. Surg.

The Ross procedure in children: preoperative haemodynamic manifestation has significant effect on late autograft re-operation

Eur. J. Cardiothorac. Surg.

The Ross procedure is the procedure of choice for congenital aortic valve disease

J. Thorac. Cardiovasc. Surg.

Inclusion cylinder method for aortic valve replacement utilising the Ross operation in adults with predominant aortic stenosis- 99% freedom from re-operation on the aortic valve at 15 years

Glob. Cardiol. Sci. Pract.