Midterm Results of the Ross Procedure in a Pediatric Population: Bicuspid Aortic Valve Is Not a Contraindication

Abstract

Our objective was to analyze retrospectively the short- and midterm results of the Ross operation in children and the impact of bicuspid aortic valve (BAV) disease on outcome. From 1991 to 2003, 41 patients (26 male, 15 female) underwent a Ross procedure. Aortic disease was congenital in all but one. Sixty-six percent had BAV. Mean age at operation was 10.13 +/- 5.6 years (range, 0.4-18.3 years). Root replacement technique was performed in all but two (inclusion technique). There were two early deaths. Mean follow-up was 6 +/- 3.8 years (range, 0.1-14 years). The autograft (neo-aorta) presented absent, trivial, mild, and moderate regurgitation in 42%, 46%, 10%, and 2%, respectively, at latest follow-up. Root dilation was seen in 64% of the patients (mean Z-score, +3.53 +/- 0.04). Four patients (9%) required allograft replacement, two for endocarditis and two for stenosis. Allograft stenosis (gradient >20 mmHg) was detected in 44% of the remaining patients, without symptoms or the need for reintervention. Estimated freedom from allograft replacement at 5 and 10 years was 97% and 89%. Left ventricular dimensions and function were normal in all patients. No difference was found between patients with BAV and those with tricuspid aortic valves in aortic regurgitation or root dilation. BAV was not identified as a risk factor for root dilation. In conclusion, the Ross operation remains an excellent option for aortic valve replacement in children. BAV is not associated with a worse outcome and is not a risk factor for aortic root dilation at medium-term follow-up. Long-term follow-up is, however, required.

Ross Procedure in Children: 17‐Year Experience at a Single Institution

“…This is consistent with other studies in children where operative mortality ranged from 0% to 16%. 5,7–9,15,19–21 Takkenberg et al 12 reviewed the literature regarding the outcomes of the Ross procedure in children and adults and their meta‐analysis found, on average, an increased rate of early mortality in children (4.2%) compared to adults (3.2%). 12 In our study, patients younger than 1 year were at a higher risk of early mortality (32%, 6/19).…”

“…This is consistent with other studies in children where operative mortality ranged from 0% to 16%. 5,[7][8][9]15,[19][20][21] Takkenberg et al 12 early mortality in children (4.2%) compared to adults (3.2%). 12 In our study, patients younger than 1 year were at a higher risk of early mortality (32%, 6/19).…”

Ross operation early and mid-term results in children and young adults

“…However, more than half of the cohort had aortic root dilatation at 10 years. Reoperations for autograft failure have been reported to be between 81% and 89% (10, 11) at 10 years postoperatively. Although in the adult population various techniques for autograft support using prosthetic material have been reported (12-14), in small children, fixing the small aortic root and limiting the growth potential are not desirable.…”

Surgical Treatment of Bicuspid Aortic Valve Disease

“…Mechanical valves have an excellent freedom from reoperation, but the cumulative risk of thromboembolic complications and anticoagulation-related hemorrhage may be substantial due to the long exposure time (Khan, 2002;Salem et al, 2004). The Ross procedure is ideal for young patients with BAV stenosis because of its low operative mortality, excellent hemodynamic performance, low prevalence of infection, avoidance of anticoagulant therapy, and potential to grow in children (El Behery et al, 2009;Takkenberg et al, 2009). However, the presence of preoperative AR and aortic root dilatation are important independent determinants of reoperation for pulmonary autograft failure (Elkins et al, 2008;de Kerchove et al, 2009;Ryan et al, 2011).…”

“…Actually, any type of treatment for aortic stenosis in newborns and infants is palliative, and future aortic valve replacement is inevitable (Vida et al, 2005). Because the bioprosthetic valve has a high structural failure rate in young patients and mechanical valves have a risk of anticoagulant-related morbidity, the better option of aortic valve substitute in infants and children is the pulmonary autograft because of its potential for growth (Vida et al, 2005;Behery et al, 2009). …”