Congenital: Aortic Valve| Volume 163, ISSUE 3, P1180-1191.e6, March 2022

Ross procedure or complex aortic valve repair using pericardium in children: A real dilemma



      Difficult to repair aortic valve lesions, requiring the use of a valve substitute, remain controversial in the face of the Ross procedure, despite undeniable technical advances. This study was undertaken to compare midterm outcomes of children treated using the Ross procedure or aortic valvuloplasty for complex aortic valve lesions.


      Between January 2006 and December 2017, 126 patients aged younger than 18 years were treated for complex aortic stenosis and/or aortic insufficiency and were included in this retrospective study. Only aortic valve lesions requiring repair with an autologous or heterologous pericardial patch were considered complex lesions. Propensity score framework analyses were used to compare outcomes of the Ross and aortic valvuloplasty groups while controlling for confounders.


      Among the 126 patients with complex aortic valve lesions, propensity score matching selected 34 unique pairs of patients with similar characteristics. Survival (aortic valvuloplasty, 94.1%; Ross, 91%; P = .89), freedom from overall reintervention (aortic valvuloplasty, 50.1%; Ross, 69%; P = .32), and freedom from infective endocarditis at 8 years (aortic valvuloplasty, 100%; Ross, 85.9%; P = .21) were similar. However, freedom from reintervention in the left ventricular outflow tract at 8 years was lower after aortic valvuloplasty than after the Ross procedure (50.1% vs 100%, respectively; P = .001).


      Aortic valvuloplasty and the Ross procedure yielded similar 8-year outcomes regarding death, reoperation, and infective endocarditis although aortic valvuloplasty tended to be associated with fewer cases of infective endocarditis. Aortic valvuloplasty using a pericardial patch can be chosen as a first-line strategy for treating complex aortic valve lesions and might offer the possibility of a later Ross procedure.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AI (aortic insufficiency), AS (aortic stenosis), AVR (aortic valve replacement), CI (confidence interval), IE (infective endocarditis), IQR (interquartile range), LVOT (left ventricular outflow tract), OR (odds ratio)
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      Linked Article

      • Commentary: Aortic valve surgery in children: Repair now, Ross procedure later
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3
        • Preview
          Aortic valve surgery in children presents many challenges owing to the need to accommodate ongoing somatic growth.1 The 2 widely used surgical techniques, aortic valve repair and the Ross procedure, each carries its own drawbacks. Aortic valve repair has a very low risk of mortality, yet the rate of reoperation is relatively high.2 The Ross procedure has excellent freedom from reoperation but an increased risk of mortality in neonates and infants, the need for conduit replacement, and the risk of autograft dilatation and failure, especially in young children in whom the autograft cannot be effectively stabilized.
        • Full-Text
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      • Commentary: Aortic valve intervention in children: The jury is still out
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3
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          Management of significant aortic valve disease in children remains a significant challenge, largely due to a number of factors, including concomitant presence of associated lesions requiring intervention, lack of an appropriate-size prosthesis, lack of growth potential, and the desire to avoid anticoagulation. In this scenario, the use of a pulmonary autograft in the aortic position (Ross procedure) has become a common and effective option to relieve significant stenosis and/or regurgitation, particularly in the smallest patients, albeit at the price of reconstruction of the pathway between the right ventricle and the pulmonary artery and the associated need for recurrent reinterventions.
        • Full-Text
        • PDF