The Ross Operation in Children and Young Adults: A Fifteen-Year, Single-Institution Experience

doi:10.1016/j.athoracsur.2010.12.070

The Annals of Thoracic Surgery

Volume 91, Issue 6, June 2011, Pages 1936-1942

Presented at the Fifty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 3–6, 2010.

https://doi.org/10.1016/j.athoracsur.2010.12.070 Get rights and content

Background

The optimal operation for aortic valve disease in children and young adults remains controversial. The Ross operation offers avoidance of anticoagulation and the potential for growth but is technically demanding and creates double-valve disease. The goal of this study is to report our experience with the Ross operation and the need for reintervention at intermediate follow-up.

Methods

A retrospective review of Ross operations in a single surgeon experience from 1992 to 2007 was conducted. All echocardiograms were reevaluated by a single cardiologist.

Results

The cohort included 54 patients with a mean age of 13.5 years (range 0.5 to 35 years). Pulmonary autograft implantation was accomplished using root replacement (n = 43), root inclusion (n = 9), and Dacron tube root replacement (n = 2). Follow-up was available for 47 patients (87%) at a mean length of 6.4 years. There were no deaths. Kaplan-Meier estimates of freedom from explantation at 10 years were 100% for the autograft and 71% for the homograft. Autograft insufficiency at latest follow-up was trivial in 37 patients (82%), mild in 6 patients (13%), and moderate in 2 patients (4%). Reintervention for the homograft included balloon dilation in 3 children and conduit change in 5 children (all ≤ 2 years old at initial operation).

Conclusions

The Ross operation can be performed in children and adults with low mortality and can provide a durable result for the aortic valve with a low incidence of aortic insufficiency. The need for homograft replacement during follow-up in our series was primarily limited to children who were age 2 years or younger at initial operation.

Section snippets

Patients and Methods

Approval for the study was obtained from the institutional review board at our institution. Our operative database was queried for the Ross procedure, and all patients treated consecutively were included from a single-surgeon experience (J.L.M.) from January 1992 until December 2007 at the Penn State Hershey Children's Hospital and the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Retrospective review of the medical records and available imaging studies was performed. To preclude

Survival

Follow-up including echocardiography was available for 47 patients (87%) at a mean length of 6.4 ± 3.0 years (range 1.5 to 16 years). There were no early or late deaths. One patient who underwent the Ross operation at age 5 years for combined aortic stenosis and insufficiency was subsequently treated at another institution with a combined heart-lung transplant for pulmonary cystic fibrosis at age 12 years. At the time of transplantation, the patient had moderate aortic insufficiency and no

Comment

The pulmonary autograft performed well as an aortic valve replacement in this patient cohort of children and young adults during midterm follow-up. Although moderate aortic root dilatation was common, with a mean z-score at the sinus of Valsalva of 2.2 ± 1.5, the incidence of associated aortic insufficiency was low, with moderate insufficiency in just 2 patients, and no patient had greater than moderate insufficiency. The only reintervention required for the autografts in this series was an

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Cited by (18)

The Pulmonary Autograft After the Ross Operation: Results of 25-Year Follow-Up in a Pediatric Cohort
2021, Annals of Thoracic Surgery
Citation Excerpt :
In children and young adolescents presenting with aortic valve dysfunction unamenable to successful repair is the Ross procedure the preferred option for aortic valve replacement (AVR). The survival after a Ross operation is exceeding 90% at 10 years to 20 years in experienced centers, yielding generally few deaths beyond the early postoperative period.4,6,8 This study confirmed the excellent survival perspective in patients after a simple Ross operation, but revealed younger age at the time of surgery and the need of a Ross-Konno procedure as independent risk factors for late mortality.
Progressive autograft dilation and need for later reoperation remain major concerns of the Ross procedure. The study investigates the clinical outcome after the Ross operation, including a longitudinal analysis of autograft dimensions over 25 years.
From November 1991 to April 2019, 137 patients underwent a Ross procedure at the University Hospitals of UCL (Université catholique de Louvain)-Brussels and Ghent. Inclusion criteria were less than or equal to 18 years of age and pulmonary autograft implantation by root replacement. Outcome focused on survival, reoperation rate, and autograft size evolution through linear mixed-model analysis.
A Ross or Ross-Konno operation was performed in 110 (80%) and 27 (20%) patients at a median age of 10.4 (interquartile range [IQR], 4.7-14.3) years and 0.5 (IQR, 0.04-5.2) years, respectively. Overall 10-year and 20-year survival was 87% ± 3% and 85% ± 3%, respectively, but was 93% ± 3% for isolated Ross patients. Right ventricular outflow tract–conduit exchange was required in 20.3%, whereas autograft-related reoperation was performed in 14 (10.7%) patients at a median interval of 14 (IQR, 9-16) years, for aortic regurgitation (n = 2) and autograft dilation (n = 12). Autograft z-values increased significantly at the sinus and sinotubular junction (STJ) compared with the annulus (annulus = 0.05 ± 0.38/y, sinus = 0.14 ± 0.25/y, STJ = 0.17 ± 0.34/y; P = .015). The z-value slope for autograft dimensions was significantly steeper for Ross-Konno vs Ross patients (annulus: P = .029; sinus: P < .001; STJ: P = .012), and for children having aortic arch repair (annulus: P = .113, sinus: P = .038; STJ: P = .029).
The Ross operation offers children requiring aortic valve replacement an excellent survival perspective, with an acceptable risk of autograft reoperation within the first 25 years. Contrary to the autograft annulus, dilation of the sinus and STJ size is of concern. Closer surveillance of autograft dimensions might be required in patients who underwent a Ross-Konno procedure or aortic arch reconstruction.
A Systematic Review of Infective Endocarditis in Patients With Bovine Jugular Vein Valves Compared With Other Valve Types
2017, JACC: Cardiovascular Interventions
Citation Excerpt :
In 46 papers, the investigators reported on patients who had undergone PVR with a single valve type. The 55 study populations represented 5 valve types: BJVMelody (4,5,10–18), Contegra (15,16,19–25), homograft (16,21,26–46), bioprosthetic (bovine pericardial, porcine) (11,47–57), and 1 nonbovine surgical valve not specified (15). Two papers each present 2 distinct populations of patients who underwent PVR with 2 different conduit types.
The aim of this study was to systematically evaluate the incidence of infective endocarditis (IE) in right ventricle–to–pulmonary artery conduits and valves, comparing bovine jugular vein (BJV) valves with all others.
Recent evidence suggests that the incidence of IE is higher in patients with congenital heart disease who have undergone implantation of BJV valves in the pulmonary position compared with other valves.
Systematic searches of published research were conducted using electronic databases (MEDLINE, Embase, and CINAHL) and citations cross-referenced current to April 2016. Included studies met the following criteria: patients had undergone right ventricle–to–pulmonary artery conduit or percutaneous pulmonary valve implantation, and investigators reported on the type of conduit or valve implanted, method of intervention (surgery or catheter based), IE incidence, and follow-up time.
Fifty studies (Levels of Evidence: 2 to 4) were identified involving 7,063 patients. The median cumulative incidence of IE was higher for BJV compared with other valves (5.4% vs. 1.2%; p < 0.0001) during a median follow-up period of 24.0 and 35.5 months, respectively (p = 0.03). For patients with BJV valves, the incidence of IE was not different between surgical and catheter-based valve implantation (p = 0.83).
There was a higher incidence of endocarditis with BJV valves than other types of right ventricle–to–pulmonary artery conduits. There was no difference in the incidence of endocarditis between catheter-based bovine valves and surgically implanted bovine valves, suggesting that the substrate for future infection is related to the tissue rather than the method of implantation.
Contemporary experience with surgical treatment of aortic valve disease in children
2013, Journal of Thoracic and Cardiovascular Surgery
Surgical treatment of aortic valve (AoV) disease in childhood involves complex decisions particularly in very small patients. There is no consensus regarding the optimum surgical option. The objective of this review was to analyze a contemporary experience of AoV surgery in a large children's hospital.
A retrospective review of children (aged ≤18 years) undergoing AoV repair or replacement from June 1995 to December 2011 was carried out.
A total of 285 AoV operations (97 repairs, 188 replacements) were performed on 241 patients. Hospital survival for repair was 98% and for replacements was 97%. At follow-up of repairs, there were 16 (17%) reoperations and 3 (3%) late deaths. Follow-up of AoV replacements demonstrated 31 (16%) reoperations (homograft 27, autograft 3, mechanical 1) and 8 (4%) late deaths (homograft 5, autograft 2, mechanical 1). Freedom from reintervention or death (FRD) was found to be lower in repairs for infants (P = .048) and truncal valves (P < .05). For AoV replacements, infants and patients who had concomitant CHD or homografts (P < .0001) had lower FRD. Cox regression analysis for AoV replacements identified infants and homograft root replacements at a higher risk for death/reoperation.
AoV repairs and replacements were generally found to be associated with low death and reoperation rates at long-term follow-up. Infants had a lower freedom from reintervention or death after either an AoV repair or replacement, although truncal valve repairs and AoV replacement in patients with concomitant CHD were associated with lower valve survival. Among the valve options, homograft root replacement had a higher risk of death/reoperation and lowest freedom from reintervention or death.
Aortic Valve Interventions in Pediatric Patients
2019, Seminars in Thoracic and Cardiovascular Surgery
Citation Excerpt :
The effectiveness of these adjunct techniques remains, however, to be better ascertained in larger cohort studies with longer follow-up. The results of recently published Ross cohorts are summarized in Table 2,16–20,47,54–64 showing an early morality rate of 0–3% in children and adolescents. Long-term survival ranges from 82% to 100% at 10 years and was higher in older patient cohorts.
Aortic valve (AV) disease in pediatric patients requires a complex decision process that has an impact on decades of life. The aim of this review is to summarize the current evidence surrounding AV interventions in this patient population. In neonates with critical aortic stenosis, the relative merit of surgical vs balloon valvuloplasty is debated and practices vary depending on centers’ experience with little comparative literature. In children and adolescents, AV repair has regained interest in the last decades with encouraging early and mid-term results. The Ross procedure represents the best AV replacement option as it offers growth potential, excellent hemodynamics, low rates of endocarditis, and thromboembolism without the risks of anticoagulation. Based on contemporary literature, we propose a management algorithm for children AV disease.
Pitfalls and Future Directions of Contemporary Pediatric Valve Surgery: the Case for Living Valve Substitutes
2023, Current Pediatrics Reports
Perioperative and Anesthetic Considerations in Pediatric Valvar and Subvalvar Aortic Stenosis
2023, Seminars in Cardiothoracic and Vascular Anesthesia

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Original articlePediatric cardiacThe Ross Operation in Children and Young Adults: A Fifteen-Year, Single-Institution Experience

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Survival

Comment

Lancet

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Am J Cardiol

Am J Cardiol

Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu

Original article
Pediatric cardiac
The Ross Operation in Children and Young Adults: A Fifteen-Year, Single-Institution Experience