Abstract
Objective
The Ross procedure is an important tool that offers autologous tissue repair for severe
left ventricular outflow tract (LVOT) pathology. Previous reports show that risk of
mortality is highest among neonates and infants. We analyzed our institutional experience
within this patient cohort to identify factors that most affect clinical outcome.
Methods
A retrospective chart review identified all Ross operations in neonates and infants
at our institution over 27 years. The entire study population was analyzed to determine
risk factors for mortality and define outcomes for survival and reintervention.
Results
Fifty-eight patients underwent a Ross operation at a median age of 63 (range, 9-156) days.
Eighteen (31%) were neonates. Eleven (19%) patients died before hospital discharge.
Multiple regression analysis of the entire cohort identified young age (hazard ratio
[HR], 1.037; P = .0045), Shone complex (HR, 17.637; P = .009), and interrupted aortic arch with ventricular septal defect (HR, 16.01; P = .031) as independent predictors of in-hospital mortality. Receiver operating characteristic
analysis (area under the curve, 0.752) indicated age younger than 84 days to be the
inflection point at which mortality risk increases. Of the 47 survivors, there were
2 late deaths with a mean follow-up of 6.7 (range, 2.1-13.1) years. Three patients
(6%) required LVOT reintervention at 3, 8, and 17.5 years, respectively, and 26 (55%)
underwent right ventricular outflow tract reintervention at a median of 6 (range,
2.5-10.3) years.
Conclusions
Ross procedure is effective in children less than one year of age with left sided
obstructive disease isolated to the aortic valve and/or aortic arch. Patients less
than 3 months of age with Shone or IAA/VSD are at higher risk for morbidity and mortality.
Survivors experience excellent intermediate-term freedom from LVOT reintervention.
Graphical abstract
Graphical Abstract
Key Words
Abbreviations and Acronyms:
AI (aortic insufficiency), AS (aortic stenosis), AVR (aortic valve replacement), BAV (balloon aortic valvuloplasty), HAA (hypoplastic aortic arch), HR (hazard ratio), IAA (interrupted aortic arch), LV (left ventricular), LVOT (left ventricular outflow tract), LVOTO (left ventricular outflow tract obstruction), RVOT (right ventricular outflow tract), STS CHSD (Society of Thoracic Surgeons Congenital Heart Surgery Database), VSD (ventricular septal defect)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The Journal of Thoracic and Cardiovascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Surgical aortic valvuloplasty versus balloon aortic valve dilatation in children.World J Pediatr Congenit Heart Surg. 2016; 7: 583-591
- Ross operation or aortic valve repair in neonates and infants?.J Thorac Cardiovasc Surg. 2014; 148: 362-363
- Replacement of the aortic and mitral valves with a pulmonary autograft.Lancet. 1967; 29: 56-58
- Ross-Konno procedure in neonates: report of three patients.Ann Thorac Surg. 2004; 77: 2223-2225https://doi.org/10.1016/S0003-4975(03)01279-7
- Ross operation in neonates: a meta-analysis.Ann Thorac Surg. 2022; 113: 192-198
- Ross versus non-Ross aortic valve replacement in children: a 22-year single institution comparison of outcomes.Ann Thorac Surg. 2016; 101: 1804-1810
- Two decades of experience with the Ross operation in neonates, infants and children from the Italian Paediatric Ross Registry.Heart. 2014; 100: 1954-1959
- Ross procedure in neonates and infants: a European multicenter experience.Ann Thorac Surg. 2015; 100: 2278-2285
- Long-term survival and reintervention after the Ross procedure across the pediatric age spectrum.Ann Thorac Surg. 2015; 99: 2086-2095
- Aortic valve replacement in neonates and infants: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database.J Thorac Cardiovasc Surg. 2012; 144: 1084-1089
- Aortic valve replacement and the Ross operation in children and young adults.J Am Coll Cardiol. 2016; 67: 2858-2870
- Long-term results of the Ross procedure in a population-based follow-up.Eur J Cardiothorac Surg. 2015; 47: e164-e170
- Ross operation in children: 23-year experience from a single institution.Ann Thorac Surg. 2020; 109: 1251-1259
- The Ross procedure in patients aged less than 18 years: the midterm results.J Thorac Cardiovasc Surg. 2014; 147: 383-388
- Outcomes of the infant Ross procedure for congenital aortic stenosis followed into adolescence.J Thorac Cardiovasc Surg. 2013; 145: 1504-1511
- Midterm results of the modified Ross/Konno procedure in neonates and infants.Ann Thorac Surg. 2012; 94: 156-162
- Intermediate-term results of the Ross procedure in neonates and infants.Ann Thorac Surg. 2010; 89: 1827-1832
- Comparison of the Ross/Ross-Konno aortic root in children before and after the age of 18 months.Eur J Cardiothorac Surg. 2014; 46: 450-454
- Age-related outcomes of the Ross procedure over 20 years.Ann Thorac Surg. 2015; 99: 2077-2085
- Outcome after aortic valve replacement in children: a systematic review and meta-analysis.J Thorac Cardiovasc Surg. 2016; 151: 143-152.e1-3
- Maturation of the extracellular material of the semilunar heart valves in the mouse. A histochemical analysis of collagen and mucopolysaccharides.Anat Embryol. 1981; 162: 343-352
- Clinical pulmonary autograft valves: pathologic evidence of adaptive remodeling in the aortic site.J Thorac Cardiovasc Surg. 2004; 128: 552-561
- Human semilunar cardiac valve remodeling by activated cells from fetus to adult: implications for postnatal adaptation, pathology, and tissue engineering.Circulation. 2006; 113: 1344-1352
- Outcomes and short-term follow-up in complex Ross operations in pediatric patients undergoing Damus-Kaye-Stansel takedown.Semin Thorac Cardiovasc Surg. 2016; 28: 81-89
- Is Ross operation in neonates and infants justified? Aortic valve repair may postpone Ross operation.Eur J Cardiothorac Surg. 2015; 47: e170-e171
- Roadmap for Ross procedure: staged strategy.J Thorac Cardiovasc Surg. 2022; 163: 379-382
- Commentary: aortic valve surgery in children: repair now, Ross procedure later.J Thorac Cardiovasc Surg. 2022; 163: 1193-1194
- Ross procedures in children with previous aortic valve surgery.J Am Coll Cardiol. 2020; 76: 1564-1573
- Aortic stenosis of the neonate: a single-center experience.J Thorac Cardiovasc Surg. 2019; 157: 318-326
- 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
- The Ross-Konno procedure in neonates and infants less than 3 months of age.Eur J Cardiothorac Surg. 2018; 54: 71-77
- Surgical outcomes and autograft function after the Ross procedure in neonates and infants.Jpn J Cardiovasc Surg. 2019; 48: 305-312
- Late follow-up of 1095 patients undergoing operation for complex congenital heart disease utilizing pulmonary ventricle to pulmonary artery conduits.Ann Thorac Surg. 2003; 75: 399-410
Article info
Publication history
Published online: April 25, 2022
Accepted:
April 6,
2022
Received in revised form:
February 7,
2022
Received:
September 29,
2021
Identification
Copyright
© 2022 by The American Association for Thoracic Surgery
ScienceDirect
Access this article on ScienceDirectLinked Article
- Commentary: Ross for all and all for Ross?The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 1
- PreviewOne wonders whether, in his wildest dreams, Donald Ross would have anticipated the benefits of his procedure being extended successfully to babies.1 Indeed, although the performance of the Ross procedure in a neonate requires considerable technical mastery, the gratification of a “living” valve that has the potential to grow over a child's lifetime is profound. Yet, of the innumerable lessons learned over the 50 years since this initial report, one of the most salient for newborns and infants has been the high mortality associated with performing a Ross in the setting of concomitant mitral valve disease, endocardial fibroelastosis, or multilevel left-sided obstructive lesions.
- Full-Text
- Preview
