Growth of Pulmonary Autograft after Ross Operation in Pediatric Patients

Abstract

The Ross procedure is being used increasingly to treat aortic valve disease in pediatric patients; however, there is an ongoing dispute about the durability of the autograft. From November 1996 to September 2003, 32 pediatric patients (mean age, 11 +/- 4.5 years) underwent the Ross procedure for various aortic valve diseases, using the root replacement technique. Clinical and echocardiographic follow-up was performed early (within 30 days), at 3 to 6 months, and yearly after surgery. There were no perioperative deaths. The patients were followed-up for up to 7 years with a median interval of 36 months. Actuarial survival at 7 years was 96% +/- 3% and there was 100% freedom from re-operation for autograft valve dysfunction or any other cause. The autograft annulus and sinus increased significantly in size during follow-up and the increase in size paralleled the increase in body surface area, with no evidence of disproportional dilatation. The hemodynamics at the latest follow-up were also similar to those at the time of discharge after surgery. Pulmonary autograft replacement of the aortic valve appears to be the ideal solution in pediatric patients, because of relatively low operative risk, excellent late valve function, and real potential for growth.

Aortic Root and Ascending Aortic Replacement Bentall or Ross Procedure?

“…A reported growth capacity and a proposed superior quality of life as a result of the aforementioned factors remain central arguments for the implementation of the Ross procedure in children and young adolescents. 6,7) Patients with aortic valvular disease occasionally present with a dilation of the ascending aorta that necessitates they undergo simultaneous aortic surgery. This leads to further complexity and prolongation of the operative procedure, which might result in higher morbidity and mortality.…”

The Helical Ventricular Myocardial Band of Torrent-Guasp

“…5). To prevent subsequent pulmonary autograft regurgitation, a minimal amount of muscle should be removed [84], since the muscle is a not a supporting structure for the semilunar valve, as confirmed by the reported clinical results [80,85].…”

Reply to Raja

“…Their finding that 90% of autograft diameters indexed to body surface area was above the 90th percentile of normal aortic root diameters at latest follow-up is not only greater than what others have reported [2,3] but is also alarming as progressive autograft dilatation leads to regurgitation, which ultimately culminates in autograft valve dysfunction prompting reoperation.…”

“…Negligible valve-related morbidity, freedom from chronic anticoagulation, ability to accommodate growth and, most importantly, scarcity of alternative treatment options make Ross operation a valid and attractive therapeutic modality in the infant and child with aortic valve disease or complex left heart obstruction [3,4]. However, a very high prevalence rate of autograft dilatation in the series of Hazekamp et al [1] makes one wonder if reality is just the opposite.…”

“…Possible explanations for this finding include wider adoption of root replacement technique, greater likelihood of geometric mismatch of aortic and pulmonary roots, and physiological dilatation (i.e. root growth) in children undergoing the Ross operation [3,4]. However, a better way of finding out the pathology of autograft dilatation will be to subject explanted autografts to histopathological analysis to look for features such as focal interruption of the media of the vessel wall with total absence of elastin fibers and intimal proliferation with fibrosis, and ischemic damage to the wall of the pulmonary autograft root replacement caused by division of the vasa vasorum of the pulmonary artery from the coronary arteries during the Ross operation which may be a more logical explanation for autograft dilatation.…”