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.
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.
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.
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.
Abbreviations and Acronyms:AI (aortic insufficiency), VSRR (valve-sparing root replacement)
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- Replacement of aortic and mitral valves with a pulmonary autograft.Lancet. 1967; 2: 956-958
- The Ross procedure: a systematic review, meta-analysis, and microsimulation.Circ Cardiovasc Qual Outcomes. 2018; 11: e004748
- Two decades of experience with the Ross operation in neonates, infants and children from the Italian Paediatric Ross Registry.Heart. 2014; 100: 1954-1959
- Autograft reinforcement to preserve autograft function after the ross procedure: a report from the German-Dutch Ross Registry.Circulation. 2009; 120: S146-S154
- A review of pulmonary autograft external support in the Ross procedure.Expert Rev Med Devices. 2019; 16: 981-988
- Type A aortic dissection after the Ross procedure.Ann Thorac Surg. 2018; 106: e105-e106
- Surgical repair of aortic dissection 16 years post-Ross procedure.J Surg Case Rep. 2016; 2016: rjw05
- Long-term outcomes after elective isolated mechanical aortic valve replacement in young adults.J Thorac Cardiovasc Surg. 2014; 148: 1341-1346.e1
- Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.N Engl J Med. 2017; 377: 1847-1857
- Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397
- Valve-sparing aortic root surgery in children and adults with congenital heart disease.J Thorac Cardiovasc Surg. 2021; 162: 955-962
- Aortic root aneurysm: principles of repair and long-term follow-up.J Thorac Cardiovasc Surg. 2010; 140 (discussion S45-51): S14-S19
- Early results of a novel technique for ring-reinforced aortic valve and root restoration.Eur J Cardiothorac Surg. 2014; 45: 426-430
- Geometric ring annuloplasty for aortic valve repair during aortic aneurysm surgery: two-year clinical trial results.Innovations (Phila). 2018; 13: 248-253
- Root remodeling for aortic root dilatation.Ann Cardiothorac Surg. 2013; 2: 113-116
- Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure.Ann Thorac Surg. 2003; 75: 1518-1522
- Aortic root replacement using the reimplantation technique: tips and tricks.Interact Cardiovasc Thorac Surg. 2009; 8: 584-586
- Geometric ring annuloplasty as an adjunct to aortic valve repair: clinical investigation of the HAART 300 device.Eur J Cardiothorac Surg. 2016; 49: 987-993
- Long-term survival and reintervention after the Ross procedure across the pediatric age spectrum.Ann Thorac Surg. 2015; 99 (discussion 2094-5): 2086-2094
- Fate of the aortic root late after Ross operation.Circulation. 2003; 108: II61-II67
- Age-related outcomes of the Ross procedure over 20 years.Ann Thorac Surg. 2015; 99 (discussion 2084-5): 2077-2083
- Long-term outcomes of patients undergoing the Ross procedure.J Am Coll Cardiol. 2021; 77: 1412-1422
- The Ross procedure: outcomes at 20 years.J Thorac Cardiovasc Surg. 2014; 147: 85-93
- A progress report on reimplantation of the aortic valve.J Thorac Cardiovasc Surg. 2021; 161: 890-899.e891
- Valve-sparing root replacement: where are the limits?.Tex Heart Inst J. 2011; 38: 661-662
- Should root replacement with aortic valve-sparing be offered to patients with bicuspid valves or severe aortic regurgitation?.Eur J Cardiothorac Surg. 2010; 38: 515-522
- Aortic valve repair with a newly approved geometric annuloplasty ring in patients undergoing proximal aortic repair: early results from a single-centre experience.Eur J Cardiothorac Surg. 2020; 57: 1137-1144
- Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: a systematic review and meta-analysis.Ann Thorac Surg. 2015; 100: 1126-1131
Published online: April 30, 2022
Accepted: April 16, 2022
Received in revised form: April 10, 2022
Received: May 26, 2021
The University of Michigan Institutional Review Board has waived the requirement for Informed Written Consent for Publication for this retrospective analysis.
© 2022 by The American Association for Thoracic Surgery
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- 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.