A Critical Reappraisal of the Ross Operation

Abstract

Background-The autograft procedure, an option in aortic valve replacement, has undergone technical evolution. A considerable debate about the most favorable surgical technique in the Ross operation is still ongoing. Originally described as a subcoronary implant, the full root replacement technique is now the most commonly used technique to perform the Ross principle. Methods and Results-Between June of 1994 and June of 2005, the original subcoronary autograft technique was performed in 347 patients. Preoperative, perioperative, and follow-up data were collected and analyzed. Mean patient age at implantation was 44Ϯ13 years (range 14 to 71 years; 273 male, 74 female). Bicuspid valve morphology was present in 67%. The underlying valve disease was aortic regurgitation in 111 patients, stenosis in 46 patients, combined lesion in 188 patients, and active endocarditis in 22 patients (in 2 patients without stenosis or regurgitation). Concomitant procedures were performed in 130 patients. Clinical and echocardiographic follow-up visits were obtained annually (mean follow up 3.9Ϯ2.7 years, 1324 patient-years; completeness of follow-up 99.4%). The in-hospital mortality rate was 0.6% (n ϭ2), and the late mortality was 1.7% (nϭ6), with 5 noncardiac deaths (4 cancer, 1 multiorgan failure after noncardiac surgery) and 1 cardiac death (sudden death). At last follow-up, 94% of the surviving patients were in New York Heart Association class I. Ross procedure-related valvular reoperations were necessary in 9 patients: Three received autograft explants, 5 received homograft explants, and 1 received a combined auto-and homograft explant. At last follow-up visit, autograft/homograft regurgitation grade II was present in 5/10 patients and grade III in 4/0. Maximum/mean pressure gradients were 7.4Ϯ6.2/3.7Ϯ2.1 mm Hg across the autograft and 15.3Ϯ9.4/ 7.6Ϯ5.0 mm Hg across the right ventricular outflow tract, respectively. Aortic root dilatation was not observed.Freedom from any valve-related intervention was 95% at 8 years (95% confidence interval 91% to 99%). Conclusion-Midterm

Survival Comparison of the Ross Procedure and Mechanical Valve Replacement With Optimal Self-Management Anticoagulation Therapy

“…The required sample size of 238 patients in each treatment group was based on the use of a 2-tailed value of Pϭ0.05 to indicate statistical significance for late survival with a minimum power of 0.80. We assumed a late mortality rate of 0.45%/y for patients with the Ross procedure 20 and of 1.40%/y for patients with a mechanical prosthesis 6 with a study duration of 14 years (1994 to 2008) and a constant accrual of patients.…”

Autograft Regurgitation and Aortic Root Dimensions After the Ross Procedure

“…Details of the operative techniques have been described elsewhere. [7][8][9] Informed consent was obtained from all patients; the study was approved by the local ethics committee. The authors had full access to and take full responsibility for the integrity of the data.…”

Autograft Reinforcement to Preserve Autograft Function After the Ross Procedure

“…[1][2][3][4][5] After a renewal of interest in this procedure in the early 90s, long-term results of these procedures are beginning to emerge, and it is well established that autograft function may deteriorate over time eventually requiring replacement. [1][2][3][4][5][6][7][8] Several teams have used autograft reinforcement interventions (R) to treat underlying abnormalities and to stabilize the components of the aortic root 8 -11 in an attempt to prevent autograft failure. These reports include small number of patients and provide short follow-up, which in combination with the low incidence of autograft failure itself may be insufficient to evaluate the effects of such additional procedures.…”