Central Message
Aortic valve repair may postpone a Ross operation into adolescence or adulthood, when the autograft can be effectively stabilized.
See Article page 1180.
Edward Buratto, MBBS, PhD, FRACS, and Igor E. Konstantinov, MD, PhD, FRACS at the Royal Children's Hospital.
Aortic valve surgery in children presents many challenges owing to the need to accommodate ongoing somatic growth.
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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.3
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So far, the roles of these 2 techniques have yet to be clearly defined.In an important article in this issue of the Journal, Danial and colleagues
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compare the outcomes of the Ross procedure and complex aortic valve repair (ie, repair necessitating the use of a patch). They report that early mortality was similar in their 2 groups of patients, and that freedom from reoperation for both groups was approximately 50% at 10 years. They concluded that complex aortic valve repair may be used as a first-line strategy, allowing the Ross to be delayed into later childhood or adulthood.Over the last few years, it has become increasingly apparent that an initial approach of surgical aortic valve repair in children provides excellent survival and acceptable freedom from reoperation.
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A strategy of avoiding balloon dilatation with uncontrolled tear of the aortic valve allows for a good quality initial repair and as such results in better freedom from reintervention.6
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Although the Ross procedure is associated with increased mortality in infants and neonates, it has excellent outcomes in older children.4
We have recently demonstrated that the autograft has improved durability when the Ross procedure is performed as a reoperation, presumably due to a degree of natural stabilization from postoperative scarring.3
Furthermore, excellent results have been demonstrated with the Ross procedure in adolescents and young adults with stabilization of the autograft.8
As such, we have increasingly aimed to repair valves, with the hope of delaying the Ross procedure until the child is fully grown and the autograft can be stabilized.There have been some concerns that complex valve repair, particularly using patch material, may increase the risk of aortic valve reoperation.
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Yet even complex repair with patches may delay the Ross procedure for a prolonged period to allow for longitudinal growth of a child, with the Ross performed at a later age.10
Danial and colleagues have provided important additional information, demonstrating that complex aortic valve repair with the use of patch material can provide similar freedom from reoperation to the Ross procedure.5
These findings should encourage us to continue to push the boundaries of which aortic valves can be repaired. In doing so, it should be possible to delay the Ross procedure for as long as possible and, hopefully, minimize the lifetime risk of prosthetic aortic valve replacement.References
- Aortic valve surgery in children.J Thorac Cardiovasc Surg. 2021; 161: 244-250
- Aortic valve repair in children without use of a patch.J Thorac Cardiovasc Surg. December 13, 2020; ([Epub ahead of print])
- Ross procedures in children with previous aortic valve surgery.J Am Coll Cardiol. 2020; 76: 1564-1573
- Ross operation in children: 23-year experience from a single institution.Ann Thorac Surg. 2020; 109: 1251-1259
- Ross procedure or complex aortic valve repair in children: a real dilemma.J Thorac Cardiovasc Surg. 2022; 163: 1180-1191.e6
- Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization.J Am Coll Cardiol. 2013; 62: 2134-2140
- Aortic stenosis of the neonate: a single-center experience.J Thorac Cardiovasc Surg. 2019; 157: 318-326.e1
- Improved survival after the Ross procedure compared with mechanical aortic valve replacement.J Am Coll Cardiol. 2018; 71: 1337-1344
- Long-term results of a strategy of aortic valve repair in the pediatric population.J Thorac Cardiovasc Surg. 2013; 145 (discussion 467-9): 461-467
- Road map for Ross procedure: staged strategy.J Thorac Cardiovasc Surg. January 13, 2021; ([Epub ahead of print])
Article info
Publication history
Published online: March 23, 2021
Accepted:
March 18,
2021
Received in revised form:
March 17,
2021
Received:
March 17,
2021
Footnotes
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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Copyright
Crown Copyright © 2021 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery
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- Ross procedure or complex aortic valve repair using pericardium in children: A real dilemmaThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3
- PreviewDifficult 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.
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