Commentary: The pulmonary autograft, too valuable to repeal.

Recognizing the value of the Ross procedure, interest in salvaging failed autografts is gaining acceptance in the surgical community.

See Article page 408.

Ever since Donald Ross introduced the Ross procedure, controversy has existed surrounding the role of the procedure in managing aortic valve disease. Not many surgical procedures have been more scrutinized in the literature. Initially the Ross procedure was doomed because of its intrinsic complexity, but when excellent outcomes were reported in the 1980s, and with the introduction of the technique of full aortic root replacement, which is technically easier and more forgiving, enthusiasm grew rapidly—probably too greatly! As the indications were broadened, problems started to appear, which resulted in a surge of manuscripts raising red flags. Suddenly, enthusiasm dampened significantly, a pattern that often occurs with technology triggers and is shown in a graphical presentation known as the “hype curve” (Figure 1).

Figure 1

The hype curve.

As experience has accumulated and indications have been refined, I believe that we have reached the “plateau of productivity” of the hype curve for the Ross procedure. In the procedure, the patient's own pulmonary valve is used to replace the aortic valve. The valve must function perfectly or else the patient will probably end up with a different valve in the aortic position and lose the original pulmonary valve to a substitute requiring lifelong surveillance. Proper selection criteria hopefully can ensure that this does not happen.

It should be emphasized that not all aortic valve pathologies are suitable for the Ross procedure. In pediatric age groups, including neonates and infants, the situation is different, as the options for that age group are limited, and the Ross procedure is often the best option.

Nevertheless, for some reason or another, some autografts will fail. Keeping in mind that the autograft is valuable and should not be readily discarded, the concept of salvaging the autograft emerged.

In this issue of JTCVS Techniques, Goldstone and Woo present a concise overview of valve-sparing reoperations for failed pulmonary autografts. Although this very much depends on the mechanism of autograft failure, still salvage rates of up to 50% can be achieved in experienced hands. We agree with the authors' statement that mechanisms of failure are basically due to either root dilatation or leaflet malfunction; however, we know the subgroup of patients who will develop root dilatation, and those patients simply should not be offered the Ross procedure. In our experience with more than 600 Ross patients, after going through the pains of the hype curve, we mostly eliminated this group. Unfortunately, leaflet malfunction cannot be eliminated completely and will remain the main mechanism for autograft failure. Technically salvaging autografts is more difficult but is worth attempting. We should always keep in mind that the autograft is too valuable to repeal.