Highlights of a ten-year experience with the Ross procedure.

BACKGROUND: A review of a 10-year experience with the Ross procedure as a root replacement by a single group of surgeons featuring specific highlights is presented. Highlights include our results from a subset of patients with endocarditis and their management and a comparison of outcomes in patients with aortic insufficiency based on technical changes made after 5 years' experience. METHODS: The total patient group was 191, with 148 male and 43 female participants with an age range from 1 day to 69 years. Five of the patients in the 0-to-20 age group were newborns. Fifty-three of the adults were operated on for infectious endocarditis. In the total patient group 43% had aortic insufficiency, 28% had aortic stenosis, and 29% had mixed disease. RESULTS: Operative mortality was 5.2% with a late mortality of 2.6%. The actuarial survival was 90.2% at 10 years. Freedom from autograft explantation was 93.2% and freedom from homograft replacement was 98.4%. The endocarditis patients had an operative mortality of 3.8% with 100% cure of the infection. Freedom from reinfection on the autograft was 98.1%, and freedom from infection of the pulmonary homograft was 98.1%. The actuarial survival was 86.3%. CONCLUSIONS: A specific review of the patients with aortic insufficiency resulted in a failure of the autograft in 7 patients among a cohort of 41 during the first 5 years of the study. After a change in technique in which the aortic annulus is narrowed and fixed to a measured size to match the body surface area, we have had no failures in the autograft. Although these results are early, we believe that these data support the use of the autograft as an excellent choice for replacement of the aortic valve in infective endocarditis. Finally, the use of the autograft for aortic insufficiency is reasonable with fixation of the aortic annulus so that subsequent dilation does not occur.

Complex valvular procedures: ross, mitral, redos--time enough?

The possibility of a lengthy ischemic time is considered when evaluating complex valvular procedures. This consideration or even worry may influence the choice of valve replacement, repair offered, or actual acceptance of the case because of expected outcomes. With the use of an integrated, streamlined blood cardioplegic delivery, we believe these complex valvular procedures, even combined with revascularization, can be managed with good results. Additionally, this technique allows for sufficient protection to teach these same complex valvular repairs. A summary of a 10-year personal experience with the Ross procedure in 120 patients is covered. Aortic stenosis, insufficiency, and, particularly, infective endocarditis, have been managed with an overall surgical mortality rate of 2.5%. The endocarditis subset has a mortality of 0% with 100% cure of the infection. Data regarding complex mitral repairs and replacement are likewise included.

Acceptance and versatility of the Ross procedure.

During the 31 years since the initial Ross procedure, data have been collected that have been helpful in assessing long-term performance of the autograft. The ongoing study of the pulmonary autograft supports the use of the Ross procedure in young patients, in females of childbearing age, and in patients with congenital aortic stenosis and complex left ventricular outflow tract obstruction. We continue to see little or no thromboembolism despite no anticoagulation therapy. The remarkable ability of the autograft to grow in children is extremely beneficial. Additionally, excellent results have been obtained in some series for the treatment of endocarditis. Recently, the autograft has performed similarly to a normal aortic valve under high stress. Changes in implantation techniques transitioning from subcoronary to root replacement and performing annular narrowing has decreased the incidence of early regurgitation. A potential for an immune response with resulting pulmonary stenosis and possible early explanation of the pulmonary homograft exists; however, overall, results of the Ross procedure are excellent and highly reproducible.

Exercise-induced fragmentation hemolysis: a simple in vivo test to evaluate heart valve hemolysis.

Differentiating heart valve-related fragmentation hemolysis from other causes of hemolysis can occasionally be difficult, especially when findings on transthoracic or transesophageal echocardiography are minimal. We report a case in which the cause of hemolysis remained in doubt after thorough hematologic and cardiologic evaluations. The decision to reoperate on the valve was finally made, based on the result of exercise-induced increase in serum hemoglobin. Hemolytic anemia promptly resolved after reoperation. We believe this to be the first reported use of this in vivo test to support the diagnosis of valve-related hemolytic anemia.

Cardiopulmonary response to maximal exercise in young athletes following the Ross procedure.

BACKGROUND: Aortic prosthetic devices offer limitations that make them less than optimal valve substitutes because the vast majority are innately obstructive, especially at increased levels of hemodynamic function. The present study is designed to demonstrate the hemodynamics of the pulmonary autograft in 11 conditioned athletes who have undergone the Ross (pulmonary autograft) procedure. Data was compared to a group of 13 age-matched "normal athletes." METHODS: All the Ross athletes had undergone the autograft procedure using the root replacement technique and were at least 3 months into their postrecovery phase. All athletes (both normal and Ross) underwent resting transthoracic echo followed by maximal exercise stress test (modified Bruce protocol) to exhaustion. Post-operative transesphogeal echocardiogram obtained within 90 seconds documented aortic valve gradient and velocity across the aortic valve. RESULTS: In the Ross athlete group, maximum heart rate was 188 beats per minute, peak aortic valve gradient at rest (mm Hg) 7.69 (mean), velocity across the aortic valve at rest (cm per second) 129.40 (mean), peak aortic valve gradient at maximal exercise (mm Hg) 16.30 (mean), velocity across the aortic valve at maximal exercise (cm per second) 190.00 (mean). In the normal athlete group, maximum heart rate was 176 beats/minute, peak aortic valve gradient at rest (mm Hg) 5.97 (mean), velocity across the aortic valve at rest (cm per second) 120.54 (mean), peak aortic valve gradient at maximal exercise (mm Hg) 14.61 (mean), velocity across the aortic valve at maximal exercise (cm per second) 190.23 (mean). CONCLUSION: The pulmonary autograft exhibits hemodynamic characteristics similar to the normal human aortic valve under conditions of enhanced cardiac output.

Aortic infective endocarditis managed by the Ross procedure.

The excellent clinical results with homografts inserted for aortic endocarditis encouraged us to take this method one step further, believing that the placement of a pulmonary autograft which is totally viable and antibiotic-perfused would be an even better choice for valve replacement. We applied this technique in 13 consecutive patients with infective aortic endocarditis, achieving excellent early results. Our follow up extending to 30 months continues to show excellent results with 0% re-infection and 0% mortality. We conclude from our experience that this technique affords excellent results in curing the infection with the lowest chance of thromboembolism, the lack of need for anticoagulation and only a small chance of reoperation in the future.

Myocardial vs serum digoxin concentrations in infants and adults.

To establish whether there is a difference between infants and adults in the relationship of serum levels of digoxin to dosage or the ratio of myocardial to serum digoxin levels, the concentrations of digoxin in right atrial appendage (RAA) and serum were measured in 12 infants and 17 adults undergoing open heart surgery. Although the daily digoxin dose per weight for the infant was significantly greater than that for adults, there was no difference in the serum digoxin levels for the two groups. We found, however, a considerable difference in myocardial digoxin levels. The RAA digoxin levels were 211.8 +/- 72.1 ng/g of wet weight in infants and 35.1 +/- 7.7 ng/g of wet weight in adults. Similarly, the RAA-serum digoxin ratio was much higher in infants (149 +/- 30) than in adults (28 +/- 5). These data indicate discrepancies between infants and adults in the pharmacokinetics of digoxin, especially with respect to myocardial uptake.