Abstract
Objectives
The Ross procedure is a preferred treatment for infants and children with aortic valve
disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur
after the Ross procedure, and because of the young age of these patients, valve-sparing
aortic root replacement procedures have advantages compared with the Bentall procedure.
The aim of this study is to describe our experience with different techniques of aortic
valve-sparing root replacement in this unique cohort of patients.
Methods
Patients undergoing valve-sparing aortic root replacement with a history of the Ross
procedure between January 2001 and March 2021 were identified. A retrospective chart
review was performed, and clinical characteristics of these patients were analyzed.
The results of different types of valve-sparing aortic root replacement were also
compared.
Results
Forty-two patients who had previously undergone a Ross procedure in childhood presented
for reintervention for neoaortic root or valve pathology. Seventeen of these patients
were considered for valve-sparing aortic root replacement but underwent bioprosthetic
or mechanical valve replacement, and 25 patients underwent successful valve-sparing
aortic root replacement. Patients who underwent valve-sparing aortic root replacement
received a traditional aortic root remodeling procedure with or without suture annuloplasty
(Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David
technique, group 2, n = 11), or a modified root remodeling procedure that also used
a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities
were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years,
and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage
in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1;
1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency,
whereas none in group 3 have required any reintervention. Overall, patients requiring
valve replacement after valve-sparing aortic root replacement had lower grades of
preoperative neoaortic insufficiency and higher grades of postoperative neoaortic
insufficiency. Greater than mild postoperative neoaortic insufficiency was associated
with the need for subsequent neoaortic valve replacement.
Conclusions
Valve-sparing aortic root replacement is safe in patients with a prior Ross procedure.
Reimplantation offers superior durability compared with the traditional remodeling
procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram
should prompt additional attempts at valve repair. A modified remodeling procedure
with geometric ring annuloplasty that is personalized to the patient's individual
anatomy is safe with good short-term results, but longer follow-up is needed.
Graphical abstract
Graphical Abstract
Key Words
Abbreviations and Acronyms:
AI (aortic insufficiency), VSRR (valve-sparing root replacement)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: April 30, 2022
Accepted:
April 16,
2022
Received in revised form:
April 10,
2022
Received:
May 26,
2021
Footnotes
The University of Michigan Institutional Review Board has waived the requirement for Informed Written Consent for Publication for this retrospective analysis.
Identification
Copyright
© 2022 by The American Association for Thoracic Surgery
ScienceDirect
Access this article on ScienceDirectLinked Article
- Commentary: Goldi-Ross and the 3 VSRRsThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 1
- PreviewAlthough autograft reinforcement at the time of Ross may mitigate the risk of progressive root dilatation for adult-sized patients, such techniques are generally not used in growing children. Thus, Hobbs and colleagues1 offer important insight on the management of what will be an ongoing clinical problem for the relatively young. In this population, the benefits to native aortic valve preservation go well beyond avoidance of anticoagulation therapy. Hobbs and colleagues1 review a series of 25 teenagers and young adults (median age, 21 years) who underwent valve-sparing aortic root replacement (VSRR) after the Ross procedure.
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