The reinforced full-root technique for the Ross operation: surgical considerations and operative insights.

BACKGROUND: Surgical treatment of young and middle-aged patients suffering from aortic valve disease remains an unresolved issue due to the limited durability of bioprosthetic heart valve replacements and the valve-related morbidity of patients with mechanical valve substitutes. Theoretically, the "living valve" principle of the Ross operation may represent a potentially viable solution to this dilemma. In this paper, we report on the surgical techniques of the Ross procedure and present long-term post-operative outcomes using the reinforced full-root technique. METHODS: From 1995 to 2020, a total of 832 consecutive patients (mean age, 43.4±13.7 years; 617 males) underwent a Ross operation using the full-root technique. Patients were prospectively monitored with clinical and echocardiographic follow-up. Total follow-up was 9,046 patients-years and was 92% complete. Mean-follow-up was 10.9±6.9 years (range, 0-24.9 years). RESULTS: Survival at twenty years was 92% (95% CI: 90-94%). Freedom from autograft or right ventricle to pulmonary artery connection reoperation at twenty years was 79% (95% CI: 74-85%). Eighty-nine pulmonary autograft reoperations had to be performed in eighty patients; salvage of the pulmonary autograft could be performed in forty-six of them. Fifty-seven patients required sixty-three reoperations on the right ventricle to pulmonary artery connection. Major cerebral bleeding occurred in one patient and neurological events in seventeen patients, respectively. CONCLUSIONS: Over a follow-up interval of up to twenty-five years, the Ross operation with the reinforced full-root technique demonstrated excellent survival in young and middle-aged patients. The rate of pulmonary autograft and right ventricular outflow graft reoperations were low in this patient subset. Therefore, the Ross operation with the reinforced full-root technique represents an enduring and valid treatment option in young and middle-aged patients suffering from aortic valve disease.

Additional cusp reconstruction does not compromise valve durability and mid-term survival after the David procedure: results from 449 patients.

OBJECTIVES: The aim of this study was to evaluate whether additional cusp interventions and valve types affect aortic valve-related reoperation and mortality rates after the David procedure. METHODS: Between 1997 and 2018, a total of 449 patients {372 males; mean age 54.2 [standard deviation (SD) 15.2] years, range: 12.7-79.9 years} underwent elective valve-sparing aortic root replacement (David procedure) for aortic regurgitation and were prospectively followed up clinically and echocardiographically. RESULTS: The follow-up was 94% complete. Cumulative follow-up time was 2268 patient-years [mean follow-up time 5.1 (4.3 SD) years]. Thirty-day mortality was 2.2% (n = 10). Late (>30 days) survival did not differ from that of the age- and gender-matched general population. Freedom from reoperation in patients without additional cusp reconstruction was 94% [95% confidence interval (CI) 91-98] and 92% (95% CI 88-97) at 5 and 10 years, respectively, which was not significantly different (P = 1) for patients who did require additional cusp reconstruction 98% (95% CI 95-100) and 89% (95% CI 81-99). In patients with tricuspid aortic valves (n = 338), freedom from reoperation was 96% (95% CI 94-99) and 93% (95% CI 88-97) at 5 and 10 years, respectively. Patients with bicuspid aortic valves (n = 111) had a freedom from reoperation of 94% (95% CI 89-99) at 5 years and 88% (95% CI 79-98) at 10 years (P = 0.021 for the comparison to tricuspid aortic valve). Overall, 23 patients (5%; 1%/patient-year) required reoperation with a mean interval of 4.5 (4.8 SD) months. CONCLUSIONS: The David procedure revealed low mid-term reoperation risk and excellent survival independent of adjunctive cusp interventions/valve morphology and is comparable with that of the age- and gender-matched general population.

Redo Aortic Valve Implantation After Full Root Replacement Using A Sutureless Valve Prosthesis.

We report the case of a 83-year-old man who had undergone a full root replacement with a stentless bioprosthesis 15 years earlier. He was now diagnosed with severe aortic valve regurgitation secondary to leaflet degeneration, moderate mitral regurgitation, and single-vessel coronary artery disease. To reduce cross-clamp time and technical difficulties a sutureless aortic prosthesis was used. His surgery and postoperative course were uneventful. This is the first report of the successful use of a sutureless aortic valve prosthesis in a patient after bioprosthetic full root replacement who required additional mitral repair and coronary artery bypass surgery.

The David procedure for salvage of a failing autograft after the Ross operation.

BACKGROUND: Dilatation of the pulmonary autograft is a major fear after the Ross procedure. We analyzed the results after reoperation for autograft dysfunction using a valve-sparing reimplantation technique (David procedure). METHODS: From 1995 to 2012, 645 Ross operations were performed, with 630 (98%) of these as freestanding root replacements (mean follow-up, 8.3 ± 4.6 years). Forty-nine autograft reoperations occurred in 46 patients (0.89%/patient-year). Between 2005 and 2013, reoperation using a David procedure was performed in 18 of 35 patients (52%) with autograft dilatation at a mean interval of 11 ± 3.2 years after the Ross operation. RESULTS: The mean age of 18 patients receiving a David procedure as reoperation was 49.8 ± 13.9 years; 83% were male. The 30-day reoperative mortality was zero. The mean vascular graft size used for reimplantation was 29.5 ± 1.7 mm. At a mean follow-up time of 3.2 ± 2.3 years (100% complete), all patients (18 of 18) were alive and in New York Heart Association functional class I. One patient (5%) needed valve replacement for recurrent aortic regurgitation 2.6 years after the David procedure. In the remaining patients (95%), freedom from aortic regurgitation of grade 2 or greater was 100% at 3 years (regurgitation grade <1, 14 of 17; 82%). Aortic valve gradients were clinically insignificant at 5.8 ± 2.1 mm Hg. CONCLUSIONS: Performing a David procedure was successful in the vast majority of patients with dilatation of the pulmonary autograft after a Ross operation and revealed good function of the preserved autograft at midterm follow-up. Reoperations could be performed with low perioperative morbidity and mortality.

Quo vadis pulmonary autograft--the ross procedure in its second decade: a single-center experience in 645 patients.

BACKGROUND: The enthusiasm about the advantages of a viable autologous transplant faded with recent reports of autograft deterioration and associated reoperations after the Ross procedure. This report evaluates predictors for autograft failure and outcomes extending into the second decade after a Ross procedure. METHODS: From 1995 through 2012, 645 consecutive patients (mean age, 42.3 ± 14.2 years; 76% males) underwent a Ross operation using mainly the root replacement technique (98%). They were prospectively followed up with clinical and echocardiographic evaluations. Total follow-up was 5,349 patient-years and was 96% complete. Mean follow-up duration was 8.4 ± 4.6 years (range, 0 to 17.4 years). RESULTS: Early mortality was 0.9% (n = 6). Cumulative survival at 15 years was 92.7% (95% confidence interval, 90.1% to 95.3%) and did not differ from the general German population (p = 0.261). Freedom from reoperation on the autograft or the pulmonary allograft at 12 years was 91.6% (95% confidence interval, 88.5% to 94.9%) and 95.0% (95% confidence interval, 92.8% to 97.2%), respectively. Sixty-five patients (10.1%) required a total of 78 valve-related reoperations after a Ross procedure (1.5%/patient-year) with a reoperative hospital mortality of 3.8% (n = 3). Forty-seven autograft reoperations were observed in 44 patients (0.87%/patient-year); 22 of them (47%) could be performed as a valve-sparing procedure. Preoperative aortic valve regurgitation and an aortic annulus of at least 26 mm were identified as predictors for autograft failure. CONCLUSIONS: In this large series, the Ross procedure resulted in excellent long-term survival rates with a low risk of valve-related morbidity and a considerably low rate of reoperations in young and middle-aged patients and should be considered as an important treatment option in this cohort.

Strategies for biological heart valve replacement: stentless xenografts fail to evolve into an alternative pulmonary valve substitute in a Ross procedure.

The Ross operation is a complex procedure for aortic valve replacement in which the pulmonary autograft is replaced by a homograft. However, homograft availability is becoming limited. This report evaluates the performance of porcine stentless prostheses as alternative pulmonary substitutes. Echocardiographic results from two patient cohorts were compared at time of discharge and 1 year after a Ross procedure. Thirty-three patients (median age 42 years, range 17-62 years, 76% male) received a stentless prosthesis (median size 25.6 mm, range 25-29 mm) for right ventricular outflow tract reconstruction. Clinical data were not significantly different from 106 patients (median age 47 years, range 2-68 years, 75% male) who received cryopreserved homografts (median size 26 mm, range 20-33 mm). At time of discharge, peak pressure gradients (ΔPmax ) across the stentless valve (median ΔPmax 13 mmHg, range 2-26 mmHg) were higher compared to homografts (median ΔPmax 7 mmHg, range 1-32 mmHg, p<0.001). At 1 year, gradients increased in both groups, but were significantly higher across stentless valves (median ΔPmax 23 mmHg, range 10-81 mmHg vs. median ΔPmax 13 mmHg, range 2-74 mmHg, p<0.001). Eleven patients (33%) in the stentless-valve group were classified "at risk" with a ΔPmax of ≥30 mmHg. Four of them (12%) had to be re-operated. In conclusion, stentless valves showed higher pressure gradients and their performance was inferior to cryopreserved homografts. See accompanying commentary by Ulrich Stock DOI: 10.1002/biot.201200341.

Successful postoperative activation of an adjustable annuloplasty ring (MiCardia) in recurrent ischemic mitral valve regurgitation.

We report the case of a 73-year-old patient with severe ischemic mitral regurgitation (MR). She subsequently underwent combined coronary artery revascularization and mitral valve annuloplasty using the adjustable enCorSQ device (MiCardia Corporation, Irvine, CA). Three months later she experienced recurrent symptomatic severe MR. Accessing the subcutaneous lead, activation and downsizing of the device within 45 seconds resulted in trace MR. The result was unchanged 1 month later.

A single-institution experience with the Ross operation over 11 years.

BACKGROUND: Although the Ross operation requires double-valve replacement for aortic valve pathology, it is the only autologous, aortic valve replacement available. We report a single-unit's 11-year experience. METHODS: Before August 2006, 467 patients (mean age, 41 +/- 15 years; 358 males) underwent a Ross operation. The right ventricular outflow tract was repaired with a cryopreserved pulmonary homograft. Follow-up was 94.4% complete. RESULTS: The 30-day mortality was 0.6%. The Kaplan-Meier survival estimate at 120 months was 94.4% +/- 2.9% (standard error [SE], 0.0146). Reoperation was due to autograft failure in 15 patients (7 repairs, 8 replacements), with a Kaplan-Meier freedom from autograft failure measured as reoperation or regurgitation exceeding grade II at 120 months of 94.2% +/- 2.8% (SE, 0.0142). Homograft replacement, mostly due to stenosis, occurred in 11 patients. Freedom from homograft dysfunction, defined as homograft reoperation or peak homograft gradient of 30 mm Hg or more, at 120 months was 79.3% +/- 7.3% (SE, 0.0372). Freedom from all autograft- and homograft-related reoperations at 120 months was 85.9% +/- 6.3% (SE, 0.0321). Autograft or homograft endocarditis occurred in 8 patients, and 1 patient had simultaneous endocarditis of both valves. CONCLUSIONS: Patient survival and freedom from prostheses-related events over 11 years still compares favorably with conventional heart valve prostheses. Mortality and morbidity remain low. Reoperation for autograft or homograft failure is higher than our previous reports, and endocarditis is also evident, 1.9% (9 of 467). Homograft dysfunction is higher in younger recipients.

Is the Ross operation still an acceptable option in children and adolescents?

BACKGROUND: The Ross operation is increasingly accepted as an alternative to conventional valve prostheses for children, adolescents, and young adults. We review patients younger than 20 years of age. METHODS: Of 404 Ross operations done before November 2004, 60 were young patients with a median age of 12 years (range, 1 to 20 years). The pulmonary autograft technique universally was as a free root. A cryopreserved pulmonary homograft reconstructed the right ventricular outflow tract. RESULTS: Early postoperative complications were reentry for bleeding in 2 patients and one pacemaker insertion. No thromboembolic or hemorrhagic events occurred during the follow-up of 42 +/- 27 months. Two late deaths occurred, one from myocardial infarction after 3 months and another sudden death after 5 years, probably from critical pulmonary homograft stenosis. Echocardiographic follow-up revealed a median peak gradient of 6.3 +/- 3 mm Hg across the autograft. The median pulmonary homograft peak gradient of 19.1 +/- 13.7 mm Hg was increased to more than 30 mm Hg in 6 patients. Another 6 patients had moderate but clinically insignificant pulmonary homograft regurgitation. Altogether, 6 patients required reoperation for replacement of stenotic homografts. No autograft related reoperation occurred. CONCLUSIONS: Young patients with the Ross operation had good mid-term autograft function and no perioperative mortality. Factors that justify the choice of the Ross operation for young patients are the normal physiologic hemodynamics and growth of the autograft as well as freedom from anticoagulation. A 10% reoperation rate, elevated pulmonary homograft gradients, and the surgical complexity remain limiting factors.

Older patients fare better with the Ross operation.

BACKGROUND: The Ross operation has an established position in young patients. We address the question of whether any age group profits most from the Ross operation, and we compare the results in various ages. METHODS: From February 1995 to August 2001 we performed 250 Ross operations. Group 1 consisted of 46 patients, ages 2 to 25 years (median age, 15 years). Group 2 consisted of 123 patients, ages 26 to 49 years (median age, 39 years). Group 3 consisted of 81 patients, ages 50 to 67 years (median age, 55 years). Echocardiography was performed perioperatively, at 2 to 6 months, and then yearly. RESULTS: Mean follow-up for the three groups was 32, 31, and 28 months, respectively (p = 0.36). One patient from group 2 died after 25 months caused by suppurative pneumonia and 3 patients from group 3 died (1 from suspected acute thoracic aorta dissection at 40 months, 1 from ventricular fibrillation after 25 months, and 1 from an undiagnosed sudden death at 5 months). Autograft replacement was necessary for 3 patients from group 2 and 1 from group 3. Autograft repair was necessary for 1 patient from group 2, and pulmonary homograft reoperation was necessary for 1 patient from group 1. All other autografts currently have physiologic gradients and clinically insignificant regurgitation. Median peak gradient across the right ventricular outflow tract was 23.6 +/- 18 mm Hg for group 1, 14.6 +/- 8 mm Hg for group 2, and 11.5 +/- 7 mm Hg, which was significantly lower for group 3 patients (p < 0.001). Eleven patients are under close follow-up for right ventricular outflow tract gradients > or = 40 mm Hg; eight of these patients are from group 1, 3 are from group 2, and there are none from group 3. CONCLUSIONS: Although the Ross operation provides excellent results in all age groups, the problem of right ventricular outflow tract stenosis has not been seen in patients older than 50 years, which implies that it offers superior results for aortic valve disease in middle aged and older patients.