S Ram Kumar1, Neeraj Bansal2, Winfield J Wells3, Vaughn A Starnes3. 1. Division of Cardiac Surgery, Department of Surgery, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital of Los Angeles, Los Angeles, California. Electronic address: ramkumar.subramanyan@med.usc.edu. 2. Division of Cardiac Surgery, Department of Surgery, University of Southern California, Los Angeles, California. 3. Division of Cardiac Surgery, Department of Surgery, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital of Los Angeles, Los Angeles, California.
Abstract
BACKGROUND: After a Ross procedure, a small subset of patients requires reintervention for autograft dilatation or valve insufficiency. We sought to determine the indications, nature, and outcomes of autograft reinterventions in the left ventricular outflow tract after a Ross procedure. METHODS: We retrospectively reviewed the charts of 316 consecutive patients, age 4 days to 70 years, who underwent a Ross procedure at our institution. Of these, 47 patients (15%) required autograft reintervention during a median follow-up of 8.2 years. RESULTS: Forty-seven patients, median age 26 years (interquartile range [IQR], 14.4 to 44.8 years), 32 (68%) men, required autograft reintervention a median 5.5 years (IQR, 1.8 to 9.4 years) after a Ross procedure. In 47% (22 of 47 patients), the autograft valve could be salvaged (15 valve-sparing aortic replacements, 7 valve repairs). The remaining 53% underwent replacement of the root (10 mechanical, 5 homograft) or valve alone (7 mechanical, 3 bioprosthetic). Twenty patients presented without autograft root dilatation 1 year (IQR, 0.5 to 2.9 years) after Ross. Fifteen of them (75%) required valve replacement. The 27 patients who demonstrated root dilatation presented 6.9 years (IQR, 4.5 to 9.7 years; p < 0.01 compared with the nondilated group) after Ross, and 17 (63%) of these valves could be spared (p = 0.01). There was no surgical mortality and 5 (11%) major morbidity events. Patients were followed up for 4.9 years (IQR, 2.1 to 7 years) after left ventricular outflow tract reintervention. For patients whose autograft valve could be spared, 3-, 5-, and 8-year freedom from valve replacement was 92%, 86%, and 86%, respectively. At last follow-up, only 1 patient had greater than mild aortic insufficiency, and all but 1 had normal ejection fraction. CONCLUSIONS: Autograft reintervention after a Ross appears to follow a bimodal distribution. Patients with primary autograft leaflet problems tend to present early without root dilatation and frequently require valve replacement. The autograft valve can be salvaged in the majority of patients who present later with root dilatation. Valve-sparing procedures are durable in the intermediate term and can be accomplished with low morbidity.
BACKGROUND: After a Ross procedure, a small subset of patients requires reintervention for autograft dilatation or valve insufficiency. We sought to determine the indications, nature, and outcomes of autograft reinterventions in the left ventricular outflow tract after a Ross procedure. METHODS: We retrospectively reviewed the charts of 316 consecutive patients, age 4 days to 70 years, who underwent a Ross procedure at our institution. Of these, 47 patients (15%) required autograft reintervention during a median follow-up of 8.2 years. RESULTS: Forty-seven patients, median age 26 years (interquartile range [IQR], 14.4 to 44.8 years), 32 (68%) men, required autograft reintervention a median 5.5 years (IQR, 1.8 to 9.4 years) after a Ross procedure. In 47% (22 of 47 patients), the autograft valve could be salvaged (15 valve-sparing aortic replacements, 7 valve repairs). The remaining 53% underwent replacement of the root (10 mechanical, 5 homograft) or valve alone (7 mechanical, 3 bioprosthetic). Twenty patients presented without autograft root dilatation 1 year (IQR, 0.5 to 2.9 years) after Ross. Fifteen of them (75%) required valve replacement. The 27 patients who demonstrated root dilatation presented 6.9 years (IQR, 4.5 to 9.7 years; p < 0.01 compared with the nondilated group) after Ross, and 17 (63%) of these valves could be spared (p = 0.01). There was no surgical mortality and 5 (11%) major morbidity events. Patients were followed up for 4.9 years (IQR, 2.1 to 7 years) after left ventricular outflow tract reintervention. For patients whose autograft valve could be spared, 3-, 5-, and 8-year freedom from valve replacement was 92%, 86%, and 86%, respectively. At last follow-up, only 1 patient had greater than mild aortic insufficiency, and all but 1 had normal ejection fraction. CONCLUSIONS: Autograft reintervention after a Ross appears to follow a bimodal distribution. Patients with primary autograft leaflet problems tend to present early without root dilatation and frequently require valve replacement. The autograft valve can be salvaged in the majority of patients who present later with root dilatation. Valve-sparing procedures are durable in the intermediate term and can be accomplished with low morbidity.