Original Investigation
Aortic Valve Replacement and the Ross Operation in Children and Young Adults

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Abstract

Background

There are several options available for aortic valve replacement (AVR), with few comparative reports in the literature. The optimal choice for AVR in each age group is not clear.

Objectives

The study sought to report and compare outcomes after AVR in the young using data from a national database.

Methods

AVR procedures were compared after advanced matching, both in pairs and in a 3-way manner, using a Bayesian dynamic survival model.

Results

A total of 1,501 patients who underwent AVR in the United Kingdom between 2000 and 2012 were included. Of these, 47.8% had a Ross procedure, 37.8% a mechanical AVR, 10.9% a bioprosthesis AVR, and 3.5% a homograft AVR, with Ross patients being significantly younger when compared to the other groups. Overall survival at 12 years was 94.6%. In children, the Ross procedure had a 12.7% higher event-free probability (death or any reintervention) at 10 years when compared to mechanical AVR (p = 0.05). We also compared all procedures except the homograft in a matched population of young adults, where the bioprosthesis had the lowest event-free probability of 78.8%, followed by comparable results in mechanical AVR and Ross, with 86.3% and 89.6%, respectively. Younger age was associated with mortality and pulmonary reintervention in the Ross group and with aortic reintervention in the mechanical AVR. Of all 3 options, only the patients undergoing the Ross procedure approached the survival of the general population.

Conclusions

AVR in the young achieves good results, with the Ross being overall better suited for this age group, especially in children. Although freedom from aortic valve reintervention is superior after the Ross procedure, the need for homograft reinterventions is an issue to take into account. All methods have advantages and limitations, with reinterventions being an issue in the long term for all, more crucially in smaller children.

Key Words

aortic valve disease
aortic valve replacement
congenital heart disease
Ross procedure

Abbreviations and Acronyms

AoV
aortic valve
AVR
aortic valve replacement
B-AVR
biological heterograft
CI
confidence interval
H-AVR
homograft valve
HR
hazard ratio
M-AVR
mechanical valve replacement
R-AVR
Ross procedure
RVOT
right ventricle outflow tract

Cited by (0)

This research was supported by National Institute for Health Research (NIHR) Bristol Cardiovascular Biomedical Research Unit and used data provided by the National Institute for Cardiovascular Outcomes Research, as part of the National Congenital Heart Disease Audit (NCHDA). The NCHDA is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) and within the National Health Service, United Kingdom. The views expressed are those of the authors and not necessarily those of the National Health Service, NIHR, or Department of Health. Dr. Turner has served as a proctor for Medtronic and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Sharabiani and Dorobantu contributed equally to this work.

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