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While it is the main viable option in the growing child and young adult, the Ross procedure has expanded its applicability to older patients, for whom long-term results are equivalent, if not superior, to prosthetic aortic valve replacement. Strategies aiming at mitigating long-term autograft failure from root enlargement and valve regurgitation have led some to advocate for root reinforcement with prosthetic graft material. On the contrary, we will discuss herein the rationale for a tailored approach to the Ross procedure; this strategy is aimed at maintaining the natural physiology and interplay between the various autograft components. Several technical maneuvers, including careful matching of aortic and autograft annuli and sino-tubular junction as well as external support by autologous aortic tissue maintain these physiologic relationships and the viability of the autograft, and could translate in a lower need for late reintervention because of dilation and/or valve regurgitation. [ABSTRACT FROM AUTHOR]

Half a century after the first pulmonary autograft operation (Ross operation), performed in 1967 by Donald Ross in central London, there is a very strong conviction that the Ross operation is the best available valve substitute today, not only for children, but also for younger and older adults. The Ross operation has stimulated a lot of science to do with tissue-engineering and biology of heart valves, which is a promising avenue for the future. For one of us (M.Y.), it has certainly been a privilege to be associated with the comeback of the Ross operation. [ABSTRACT FROM AUTHOR]

Background: There has been a resurgence in interest regarding the Ross procedure due to recent publications detailing positive long-term outcomes. Conversely, surgical aortic valve replacement (SAVR) with a pulmonary homograft (PH), mechanical (MV), bioprosthetic (BV), or the Ozaki procedure each has its own technical advantages and disadvantages. Therefore, we performed a network meta-analysis (NMA) comparing other alternatives to Ross procedure. Methods: Medical databases were comprehensively searched for studies comparing the Ross procedure with AVR using a PH, MV, BV, or the Ozaki procedure. Outcomes were pooled as risk ratios (RR) with their 95% confidence intervals (95% CI). Results: A total of 7816 patients were pooled for our NMA from 24 studies. Compared to Ross procedure, both BV and MV were associated with significantly higher rates of 30-day mortality of RR (2.37, 95% CI 1.20–4.67) and (1.88 95% CI 1.04–3.40), respectively, with no significant difference regarding PH or Ozaki. However, only MV was associated with a higher risk of 30-day stroke (RR 8.42, 95% CI 1.57–45.23) with no significant difference in the other alternatives, as well as 30-day MI which showed no significant differences between any of the aortic conduits compared to the Ross procedure. Regarding 30-day major bleeding, MV was associated with a higher when compared to the Ross procedure RR (4.58, 95% CI 1.94–10.85), PH was associated with a lower risk of major bleeding with RR (0.35, 95% CI 0.17–0.71), and BV showed no significant difference. With a mean follow-up duration of 8.5 years compared to the Ross procedure, BV, PH, and MV were associated with a higher risk of long-term mortality with RR (1.89, 95% CI 1.38–2.58), (1.38, 95% CI 1.0–1.87), and (1.94, 95% CI 1.52–2.47), respectively, with the Ozaki procedure showed no significant difference. Regarding long-term stroke—with a mean of 6.3-year follow-up duration—there were no significant differences between any of the aortic conduits compared to the Ross procedure. Nevertheless, long-term need for reintervention—with a mean follow-up duration of 17.5 years—was significant of higher risk with both BV and PH with RR (3.28, 95% CI 1.21–8.84) and (2.42, 95% CI 1.05–5.58), respectively, compared to Ross procedure with MV and Ozaki having no significant difference. Conclusions: The Ross procedure is a viable treatment option for patients undergoing SAVR, showing promising outcomes at short- and long-term follow-ups. [ABSTRACT FROM AUTHOR]

The inclusion technique was developed to reinforce the pulmonary autograft to prevent dilation after the Ross procedure. Anticommissural plication (ACP), a modification technique, can reduce graft size and create neosinuses. The objective was to evaluate pulmonary valve biomechanics using the inclusion technique in the Ross procedure with and without ACP. Seven porcine and 5 human pulmonary autografts were harvested from hearts obtained from a meat abattoir and from heart transplant recipients and donors, respectively. Five additional porcine autografts without reinforcement were used as controls. The Ross procedure was performed using the inclusion technique with a straight polyethylene terephthalate graft. The same specimens were tested both with and without ACP. Hemodynamic parameter data, echocardiography, and high-speed videography were collected via the ex vivo heart simulator. Porcine autograft regurgitation was significantly lower after the use of inclusion technique compared with controls (P <.01). ACP compared with non-ACP in both porcine and human pulmonary autografts was associated with lower leaflet rapid opening velocity (3.9 ± 2.4 cm/sec vs 5.9 ± 2.4 cm/sec; P =.03; 3.5 ± 0.9 cm/sec vs 4.4 ± 1.0 cm/sec; P =.01), rapid closing velocity (1.9 ± 1.6 cm/sec vs 3.1 ± 2.0 cm/sec; P =.01; 1.8 ± 0.7 cm/sec vs 2.2 ± 0.3 cm/sec; P =.13), relative rapid opening force (4.6 ± 3.0 vs 7.7 ± 5.2; P =.03; 3.0 ± 0.6 vs 4.0 ± 2.1; P =.30), and relative rapid closing force (2.5 ± 3.4 vs 5.9 ± 2.3; P =.17; 1.4 ± 1.3 vs 2.3 ± 0.6; P =.25). The Ross procedure using the inclusion technique demonstrated excellent hemodynamic parameter results. The ACP technique was associated with more favorable leaflet biomechanics. In vivo validation should be performed to allow direct translation to clinical practice. [Display omitted] [ABSTRACT FROM AUTHOR]

The Ross procedure is a preferred treatment for infants and children with aortic valve disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur after the Ross procedure, and because of the young age of these patients, valve-sparing aortic root replacement procedures have advantages compared with the Bentall procedure. The aim of this study is to describe our experience with different techniques of aortic valve-sparing root replacement in this unique cohort of patients. Patients undergoing valve-sparing aortic root replacement with a history of the Ross procedure between January 2001 and March 2021 were identified. A retrospective chart review was performed, and clinical characteristics of these patients were analyzed. The results of different types of valve-sparing aortic root replacement were also compared. Forty-two patients who had previously undergone a Ross procedure in childhood presented for reintervention for neoaortic root or valve pathology. Seventeen of these patients were considered for valve-sparing aortic root replacement but underwent bioprosthetic or mechanical valve replacement, and 25 patients underwent successful valve-sparing aortic root replacement. Patients who underwent valve-sparing aortic root replacement received a traditional aortic root remodeling procedure with or without suture annuloplasty (Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David technique, group 2, n = 11), or a modified root remodeling procedure that also used a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years, and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1; 1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency, whereas none in group 3 have required any reintervention. Overall, patients requiring valve replacement after valve-sparing aortic root replacement had lower grades of preoperative neoaortic insufficiency and higher grades of postoperative neoaortic insufficiency. Greater than mild postoperative neoaortic insufficiency was associated with the need for subsequent neoaortic valve replacement. Valve-sparing aortic root replacement is safe in patients with a prior Ross procedure. Reimplantation offers superior durability compared with the traditional remodeling procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram should prompt additional attempts at valve repair. A modified remodeling procedure with geometric ring annuloplasty that is personalized to the patient's individual anatomy is safe with good short-term results, but longer follow-up is needed. [Display omitted] [ABSTRACT FROM AUTHOR]

The Ross procedure is an excellent operation to treat children and adults with aortic valve disease. Compared to prosthetic aortic valve replacement, it provides important clinical benefits in terms of survival, hemodynamics, freedom from valve-related complications, and durability, especially in women of childbearing age. However, the Ross procedure is a longer and technically more challenging operation. As a result, the choice of procedure should be driven by patient anatomy and clinical characteristics. This highlights the importance of concentrating care in Ross reference centers where surgical expertise and experience are present to ensure patient safety and long-term effectiveness of the operation. This manuscript reviews the major and relative contraindications to the Ross procedure. [ABSTRACT FROM AUTHOR]

When replacement of the aortic valve in neonates and infants is required, the Ross-Konno procedure provides a high-quality left ventricular outflow with good mid-term durability. The procedural outcome is highly dependent on the pre-procedural condition of the neonate or infant. Most series contain substantial numbers of post-balloon valvotomy patients as emergent or urgent management of severe, acute regurgitation. In patients with compromised ventricular function, post-operative mechanical support may be required but is generally associated with a good outcome. The neonatal and infant autograft may perform better in the long term than un-supported autografts performed later in life. Early definitive or delayed treatment of left ventricular outflow tract pathology associated with aortic interruption increasingly involves an infant Ross-Konno. The procedure also has a role in the recruitment of small left ventricles. Concomitant mitral pathology or aortic obstruction magnifies complexity, but the operative approach to the Ross-Konno remains the same. [ABSTRACT FROM AUTHOR]

Aortic valve disease in children presents a considerable surgical challenge. When repair is not feasible, the Ross procedure represents the best option for replacement as it allows growth and does not require anticoagulation. However, there is a risk of progressive autograft dilatation, and eventual failure of the autograft with severe regurgitation. Autograft stabilization has proven beneficial in adults but has not been widely adopted in children undergoing the Ross procedure. We present a series of techniques for autograft stabilization which can be used at different stages of development, from infants to fully grown adolescents. [ABSTRACT FROM AUTHOR]

The objective of this study was to characterize early and midterm outcomes after the Ross/Ross-Konno procedure performed in infancy for severe aortic valve disease. Between January 1995 and December 2018, 35 infants younger than 1 year (13 neonates) underwent a Ross/Ross-Konno procedure. Patients were followed up to a median of 4.1 years (interquartile range [IQR], 2.6-9.5). Primary outcome measures were survival, early morbidity, freedom from reintervention and long-term functional and echocardiographic status. Median age at operation was 49 days (IQR, 17-135) and weight was 4 kg (IQR, 3.4-5.2). Thirty-one (89%) had undergone a previous procedure, including balloon valvuloplasty in 26 (74%). Thirty (86%) required annular enlargement (Konno incision). Five required concomitant aortic arch surgery (2 neonates, 3 infants). There were no early deaths, and 1 late death at 18 months. Freedom from reoperation was 85% (95% confidence interval [CI], 68%-93%) at 1 year, 76% (95% CI, 54%-88%) at 5 years, and 62% (95% CI, 36%-79%) at 10 years. One modified Konno was performed at 5 years after a Ross in infancy. Ten right ventricle to pulmonary artery conduits have required reintervention (2 percutaneous pulmonary valve implantations). One child required a permanent pacemaker for complete heart block. At latest follow-up, 32 (94%) of 34 survivors were asymptomatic. There was no significant change in neoaortic Z-scores between 6 weeks and latest follow-up. The neonatal and infant Ross/Ross-Konno procedure can be performed with low mortality and achieves a stable left ventricular outflow tract. Significant early morbidity reflects the preoperative condition of the patients but definitive surgery of this type can be considered as a primary approach. The Ross/Ross-Konno procedure during infancy is a safe and durable solution for aortic stenosis. It can be performed in neonates and young infants with low mortality rates. Neoaortic dimensions are stable over medium-term follow-up. Ao , Aortic valve; P , pulmonary valve; RV-PA , right ventricle to pulmonary artery; STJ , sinotubular junction. [Display omitted] [ABSTRACT FROM AUTHOR]

The ideal aortic valve substitute in young adults remains unknown. Prosthetic valves are associated with a suboptimal survival and carry a significant risk of valve-related complications in young patients, mainly reinterventions with tissue valves and, thromboembolic events and major bleeding with mechanical prostheses. The Ross procedure is the only substitute that restores a survival curve similar to that of a matched general population, and permits a normal life without functional limitations. Though the risk of reintervention is the Achilles' heel of this procedure, it is very low in patients with aortic stenosis and can be mitigated in patients with aortic regurgitation by tailored surgical techniques. Finally, the Ozaki procedure and the transcatheter aortic valve implantation are seen by many as future alternatives but lack evidence and long-term follow-up in this specific patient population. [ABSTRACT FROM AUTHOR]

The Ross procedure remains the best aortic valve replacement option for children and young adults due to the superior hemodynamics, resistance to infection, durability, and lack of thrombogenicity when compared to bioprostheses and mechanical valve options. In particular, avoiding anticoagulation in this patient population is especially advantageous. Modifications to the technique have been developed to ameliorate the most common problem following the Ross procedure: dilatation of the autograft with development of aortic regurgitation. External support of the autograft with a Dacron tube graft have demonstrated excellent early- and mid-term outcomes. In cases of left ventricular outflow tract obstruction, the externally supported Ross procedure can be combined with a Konno aortoventriculoplasty with a few simple modifications. This paper describes the technique of the externally supported Ross procedure with a Sinus of Valsalva Dacron graft (Gelweave Terumo Cardiovascular Group, Ann Arbor, MI) in patients with aortic stenosis. This paper will specifically address the subset of patients with hypoplastic aortic annuli requiring a Konno aortoventriculoplasty. [ABSTRACT FROM AUTHOR]

The following letter presents an answer of a comment of our work titled "Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up," recently published in your journal by Rangwala et al.1 As our colleagues point out, the Ross procedure has excellent survival rates but a significant risk of valve dysfunction and therefore reintervention at follow-up. Although the survival advantage with the Ross procedure appears to be consistent compared with mechanical valve substitutes, this benefit is not as clear compared with biological valve substitutes. However, biological valve substitutes also have significant reintervention rates during follow-up. The different surgical modifications of the Ross procedure have not clearly demonstrated better results in follow-up in terms of autograft reintervention. This procedure can be performed in a medium-volume center with good results as long as adequate patient selection and adequate surgical training are carried out. [ABSTRACT FROM AUTHOR]

The following letter presents a critique of the study titled "Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up," recently published in your esteemed journal. This study provides a comprehensive analysis of the long-term outcomes of the Ross procedure, focusing on survival rates and incidence of valve dysfunction over a 25-year period. Despite revealing excellent overall survival rates and promising outcomes in pediatric patients, concerns regarding valvular failure and reintervention are underscored. While acknowledging limitations, such as sample size and observational biases, this study highlights the significance of surgeon experience in mitigating adverse outcomes. This critique emphasizes the study's contribution to understanding the efficacy and challenges of the Ross procedure, advocating further research to optimize patient outcomes. [ABSTRACT FROM AUTHOR]

The Ross procedure provides excellent long-term survival, hemodynamics, freedom from valve-related complications, and quality of life. However, its usage has decreased mainly because of concerns with technical complexity and long-term durability. In the last 2 decades, the factors associated with late failure after the Ross procedure have been clearly identified. As a result, the surgical technique has been modified in order to address these issues, specifically aiming at stabilizing the autograft root at its different levels: annulus, sinus of Valsalva, and sinotubular junction; as well as mitigating the risk of pulmonary homograft dysfunction. We have implemented this systematic approach over the last decade with demonstrated safety and effectiveness. Furthermore, by breaking down the operation into its smaller steps, we believe it makes it highly reproducible in the hands of dedicated aortic reconstructive surgeons. This article details our step-by-step, systematic, and tailored approach to the Ross procedure in patients with aortic stenosis or regurgitation. [ABSTRACT FROM AUTHOR]

The management of aortic valve disease in the pediatric population is complex and requires an individualized approach and opportune application of techniques focused on each individual patient's specific anatomy, pathology, and clinical presentation. Though some patients may require variations in the approach to management, the ultimate goal should be to perform a Ross procedure when aortic valve replacement is indicated. [ABSTRACT FROM AUTHOR]

The Ross procedure represents a valid option for aortic valve replacement in young adults and was repeatedly shown to restore survival to that of the age- and sex-matched general population. However, its major drawback relies in the risk of pulmonary autograft (PA) dilation, negative histological remodeling and need for reoperation. Several techniques and materials to reinforce the PA have been proposed. They mainly include Dacron, personalized external aortic root support with a polyethylene terephthalate mesh system, autologous aortic tissue and bioresorbable materials. Synthetic materials, despite widely used in cardiac surgery, have significant biocompatibility issues with the PA and their interaction with this living structure translates into negative remodeling phenomena and disadvantageous biomechanical behaviors. Conversely, biomaterials with tailored degradable profiles might be able to reinforce while integrating with the PA and enhance its remodeling capabilities. The recent advancement in this field are here discussed. [ABSTRACT FROM AUTHOR]

To examine the role and outcomes of all interventions for aortic stenosis in children, with focus on freedom from reintervention and the aim to minimise prosthetic aortic valve replacement (pAVR) during childhood. Retrospective analysis of 194 consecutive children who underwent any aortic valve intervention for a biventricular repair strategy at a single institution between 1995 and 2017. Data were obtained from hospital records and follow-up was 100% complete. Over a 22-year period, 194 children underwent total 313 aortic valve procedures: Primary interventions were surgical valvotomy (SV)/surgical repair (SR) in 94 (48.5%), balloon valvuloplasty (BV) in 60 (30.9%), pAVR in 8 (4.1%) and Ross/Ross-Konno procedure in 32 (16.5%). Median age at first intervention was 1.1 years (interquartile range [IQR] 0.1-9.4) and varied with type of intervention: SV/SR were most common in neonates (33, 75%) and infants (35, 68%), whilst BV was most frequent in older children (42, 42%). Operative survival was 99% (2 early deaths, both in neonates with critical aortic stenosis and poor left ventricular function) and 15-year survival was 95%. A Ross procedure was performed in 79 (40.7%) patients over the 15-year study period, 1 of whom required late pAVR for autograft failure. Freedom from any reintervention after SV/SR and BV was 41% and 40% at 10 years, compared to 90% at 10 years with the Ross procedure (P < 0.001). Among neonatal SV/SR and BV, 98% required reintervention during childhood with no difference between groups. Valve morphology did not influence freedom from ultimate valve replacement. In patients who went on to have a Ross procedure, median time from initial intervention to Ross was 2.8 years (IQR 0.1-11.9) in neonates and 6.0 years (IQR 3.1-7.5) in all other age groups. Overall freedom from pAVR was 97% at 10 years and was similar in the SV/SR and BV groups. A strategy of simple valve repair and primary Ross procedure provides excellent survival and good freedom from pAVR. However, reintervention rates after simple interventions for congenital AS are high, especially in younger age groups. The Ross procedure offers the best freedom from reintervention of any technique and wider use of primary Ross in younger age groups should be considered. [ABSTRACT FROM AUTHOR]

To describe long-term outcomes of the Ross procedure in a single center and retrospective series after 25 years follow-up. From 1997-2019 we included all consecutive patients who underwent Ross procedure at our center. Clinical and echocardiographic evaluations were performed at least yearly. Echocardiographic valvular impairment was defined as at least moderate autograft or homograft dysfunction. Reintervention outcomes included surgical and percutaneous approach. 151 Ross procedures were performed (mean age 28±12years, 21 %<16years, 70 %male). After 25 years follow-up (median 18 years, interquartile range 9–21, only 3 patients lost) 12 patients died (8 %); Autograft, homograft or any valve dysfunction were present in 38(26 %), 48(32 %) and 75(51 %), respectively; and reintervention in 22(15%), 17(11%) and 38(26 %) respectively. At 20 years of follow-up, probabilities of survival free from autograft, homograft or any valve dysfunction were 63 %, 60 % and 35 %; and from reintervention, 80 %, 85 % and 67 %, respectively. The learning curve period (first 12 cases) was independently associated to autograft dysfunction (HR 2.78, 95 %CI:1.18-6.53, p = 0.02) and reintervention (HR 3.76, 95 %CI: 1.46-9.70, p = 0.006). Larger native pulmonary diameter was also an independent predictor of autograft reintervention (HR 1.22, 95 %CI:1.03-1.45, p = 0.03). Homograft dysfunction was associated with younger age (HR 5.35, 95 %CI: 2.13-13.47, p <0.001) and homograft reintervention, with higher left ventricle ejection fraction (HR 1,10, 95 %CI:1.02-1.19, p <0.02). In this 25 years' experience after the Ross procedure, global survival was high, although autograft and homograft dysfunction and reintervention rates were not negligible. Clinical and echocardiographic variables can identify patients with higher risk of events in follow up. [Display omitted] [ABSTRACT FROM AUTHOR]

Primary aortic insufficiency (AI) is a risk factor for autograft reintervention in adults undergoing the Ross procedure. We sought to examine the influence of preoperative AI on autograft durability in children and adolescents. From 1993 to 2020, 125 consecutive patients between ages 1 and 18 underwent a Ross procedure. The autograft was implanted using a full-root technique in 123 (98.4%) and included in a polyethelene terephthalate graft in 2 (1.6%). Patients with aortic stenosis (aortic stenosis group) (n = 85) were retrospectively compared with those with AI or mixed disease (AI group) (n = 40). Median length of follow-up was 8.2 years (interquartile range, 3.3-15.4 years). The primary end point was the incidence of severe AI or autograft reintervention. Secondary end points included changes in autograft dimensions analyzed using mixed-effect models. The incidence of severe AI or autograft reintervention was 39.0% ± 13.0% in the AI group and 8.8% ± 4.4% in the aortic stenosis group at 15 years (P =.02). Annulus z scores increased in both aortic stenosis and AI groups over time (P <.001). However, the annulus dilated at a faster rate in the AI group (absolute difference, 3.8 ± 2.0 vs 2.5 ± 1.7; P =.03). Sinus of Valsalva z scores increased in both groups as well (P <.001), but at similar rates over time (P =.11). Children and adolescents with AI undergoing the Ross procedure have higher rates of autograft failure. Patients with preoperative AI have more pronounced dilatation at the annulus. Akin to adults, a surgical aortic annulus stabilization technique that modulates growth is needed in children. [Display omitted] [ABSTRACT FROM AUTHOR]

Aortic valve (AV) disease in pediatric patients requires a complex decision process that has an impact on decades of life. The aim of this review is to summarize the current evidence surrounding AV interventions in this patient population. In neonates with critical aortic stenosis, the relative merit of surgical vs balloon valvuloplasty is debated and practices vary depending on centers' experience with little comparative literature. In children and adolescents, AV repair has regained interest in the last decades with encouraging early and mid-term results. The Ross procedure represents the best AV replacement option as it offers growth potential, excellent hemodynamics, low rates of endocarditis, and thromboembolism without the risks of anticoagulation. Based on contemporary literature, we propose a management algorithm for children AV disease. [ABSTRACT FROM AUTHOR]

In the sixties, Dr Donald Ross designed a surgical solution for young patients with aortic valve disease by using the patients' own pulmonary valve. The Ross procedure is the only aortic valve replacement technique that can restore long-term survival and preserve quality of life. The main failure mode of the Ross procedure is wall dilatation, potentially leading to valve regurgitation and leakage. Dilatation occurs due to the inability of the pulmonary autograft to adapt to the sudden increase in loading when exposing to aortic pressures. Previous experimental data has shown that a permanent external support wrapped around the artery can prevent the acute dilatation of the arterial wall. However, the textile support leads to stress-shielding phenomena due to the loss of mechanical wall compliance. We present a pragmatic and modular computational framework of arterial growth and remodeling predicting the long-term outcomes of cardiovascular tissue adaptation, with and without textile wrapping. The model integrates mean, systolic and diastolic pressures and assumes the resulting wall stresses to drive the biological remodeling rules. Rather than a single mean pressure or stress deviation from the homeostatic state, we demonstrate that only pulsatile stresses can predict available experimental results. Therefore, we suggest that a biodegradable external support could induce benign remodeling in the Ross procedure. Indeed, a biodegradable textile wrapped around the autograft fulfills the trade-off between prevention of acute dilatation on the one hand and recovery of arterial wall compliance on the other hand. After further validation, the computational framework can set the basis for the development of an actual biodegradable external support for the Ross procedure with optimized polymer mechanical properties and degradation behavior. [Display omitted] • Wall pulsatility is a driver of growth and remodeling in arterial tissue. • An optimized external support promotes benign adaptation in the Ross procedure. • Textile mechanical properties will prevent acute dilatation. • Polymer biodegradability can restore arterial wall compliance. [ABSTRACT FROM AUTHOR]

Aortic valve repair and the Ross procedure are widely used in children; however, it is unclear which provides the best outcomes. Patients who underwent primary aortic valve surgery from 1980 to 2018 were included. Propensity score matching was performed to adjust for baseline differences. Of 415 children, 82.7% (343/415) underwent repair and 17.3% (72/415) underwent the Ross procedure. At 15 years, survival was higher for aortic valve repair (93.9% ± 1.8% vs 80.9% ± 6.4%, P =.04); freedom from reoperation (45.7% ± 4.9% vs 48.5% ± 9.0%, P =.29) did not differ, and freedom from aortic valve reoperation was higher in the Ross procedure group (45.7% ± 4.9% vs 70.7% ± 8.0%, P <.001). When analyzed by quality of repair, acceptable repair provided the highest survival (P =.01). Acceptable repair and the Ross procedure had similar freedom from reoperation at 15 years, whereas suboptimal repair performed worse (acceptable: 54.9% ± 6.7%; Ross procedure: 48.5% ± 9.0%; suboptimal: 27.0% ± 7.7%, P <.001). Acceptable repair and the Ross procedure had similar freedom from aortic valve reoperation at 15 years, whereas suboptimal repair showed worse results (acceptable: 54.9 ± 6.7; Ross procedure: 70.7% ± 8.0%; suboptimal: 27.0% ± 7.7%, P <.001). Propensity score matching paired 66 patients who underwent the Ross procedure with 198 patients who underwent repair. At 15 years, repair was associated with better survival (98.0% ± 1.2% vs 78.5% ± 7.2%, P =.03), whereas freedom from reoperation was similar (42.6% ± 7.6% vs 50.7% ± 9.8%, P =.50). However, the Ross procedure was associated with higher freedom from aortic valve reoperation (42.6% ± 7.6% vs 72.3% ± 8.5%, P =.002). Primary aortic valve repair was associated with better survival than the Ross procedure, whereas overall freedom from reoperation was similar. When an acceptable intraoperative result was achieved, outcomes of repair were favorable. However, when the intraoperative result of repair was suboptimal, the Ross procedure showed better results. [Display omitted] [ABSTRACT FROM AUTHOR]

Abstract Objective The study objective was to examine the long-term results of the Ross procedure in a cohort of patients followed prospectively for more than 2 decades. Methods From 1990 to 2004, 212 consecutive patients with a median age (interquartile range) of 34 years (28-41) underwent the Ross procedure; 82% had congenital aortic valve disease. The technique of aortic root replacement was used in one half of the patients. Patients have been followed prospectively for a median (interquartile range) of 18.0 (14.6-21.2) years. Valve function was assessed by echocardiography. Results Cumulative mortality at 20 years was 10.8% (95% confidence interval, 6.5-17.8). Thirty patients required Ross-related reoperations and 3 for coronary artery disease. The cumulative probability of Ross-related reoperations at 20 years was 16.8% (95% confidence interval, 11.3-24.5), on the pulmonary autograft was 11.5% (95% confidence interval, 7.2-18.0), and on the pulmonary homograft was 8.2% (4.6-14.7). The implantation technique was not associated with the cumulative incidence of reoperations on the pulmonary autograft. The development of moderate or severe aortic insufficiency and pulmonary homograft dysfunction increased with time. At 20 years, the probability of aortic insufficiency was 13% (95% confidence interval, 8.0-20.3) and of pulmonary homograft dysfunction was 19.7% (95% confidence interval, 13.9-27.2). Preoperative aortic insufficiency was associated with increased odds of postoperative aortic insufficiency. Conclusions The long-term results of the Ross procedure are excellent regardless of the implantation technique, but there is a progressive deterioration of function of both semilunar valves. [ABSTRACT FROM AUTHOR]

Background Patients who undergo the Ross procedure are at increased risk of pulmonary valve (PV) homograft dysfunction. For those who require reintervention on the homograft, transcatheter PV replacement (tPVR) provides a less invasive therapeutic option than surgical PVR (sPVR). We examined the outcomes following tPVR versus sPVR in a cohort of patients who underwent the Ross procedure. Methods We performed a retrospective analysis of Ross patients age ≥14 years who underwent tPVR (n = 47) or sPVR (n = 41) at our institution. The patients’ clinical and echocardiographic data were reviewed. Results Baseline parameters, including demographic data and left ventricular and right ventricular (RV) systolic function, were similar in the 2 groups. The mean follow-up was 56 ± 24 months for the tPVR group and 89 ± 46 months for the sPVR group ( P < .001). No procedure-related mortality was noted in either group. At 6-year follow-up, there was no significant between-group difference in event-free survival (tPVR, 79% ± 7% vs sPVR, 91% ± 4%; P = .15) or PV reintervention (tPVR, 26% ± 9% vs sPVR, 8% ± 5%; P = .31). PV-associated infective endocarditis (IE) was significantly more common with tPVR (tPVR, 13% vs sPVR, 0%; P = .04), with an annualized rate of 2.98% per patient-year. In addition, there was a trend toward more valve dysfunction following sPVR (sPVR, 67% ± 8% vs tPVR, 35% ± 8%; P = .08). Conclusions In Ross patients who require reintervention on the PV homograft, both tPVR and sPVR provide low procedural mortality and comparable midterm outcome with no significant difference in mortality or PV reintervention. However, IE is more common following tPVR. A larger randomized study is needed to determine the role of each procedure in patient management. [ABSTRACT FROM AUTHOR]

Objectives This study sought to evaluate the incidence of and risk factors for conduit and stent-related outcomes following transcatheter pulmonary valve replacement (TPVR). Background Stent fracture (SF) and right ventricular outflow tract (RVOT) reintervention are among the most important adverse outcomes after TPVR using the Melody valve (Medtronic, Minneapolis, Minnesota). The conduit environment and conduit preparation practices vary among patients who undergo TPVR. Methods Data from 3 prospective Melody valve multicenter studies were pooled and analyzed. All patients who had successful implant of a Melody valve that was present at hospital discharge comprised the study cohort; patients who had TPVR into a stentless conduit comprised the analysis cohort. SF was diagnosed using protocol-specified or clinical fluoroscopy or radiography, and classified as major or minor. Results Of 358 patients who underwent catheterization with intent to perform TPVR, 309 were discharged with the Melody valve in place (study cohort) of which 251 patients had TPVR into a stentless conduit (analysis cohort). Median follow-up was 5 years. New pre-stents were placed in 68% of patients with a stentless conduit, and 22% received multiple pre-stents. At 3 years, freedom from any SF and major SF was 74 ± 3% and 85 ± 2%, respectively, and freedom from RVOT reintervention was 85 ± 2%. New pre-stents were associated with longer freedom from SF and RVOT reintervention than was no pre-stent. Conclusions Risks of SF and reintervention after TPVR with a Melody valve were reduced by implantation of pre-stents, which has become standard practice. This study supports pre-stenting as an important component of TPVR therapy. [ABSTRACT FROM AUTHOR]

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Review echocardiography and outcomes before and after Ross procedures, including patients undergoing biventricular conversion with Damus-Kaye-Stansel (DKS) takedown. A retrospective review was performed on 62 patients undergoing simple (control group) and complex Ross procedures, including 12 patients who underwent biventricular conversion with Ross operation and DKS takedown (complex). Echocardiography was reviewed preoperatively and at discharge and late follow-up. Kaplan-Meier estimates of patient survival and freedom from reintervention were obtained. In all, 62 patients had a median age of 4.5 years (interquartile range [IQR]: 1-12.5), weight of 16.4kg (IQR: 8-41), and follow-up of 3.8 years (IQR: 1.3-6). The complex DKS takedown group had 2 deaths, no neoaortic valve or root reinterventions, and 3 right ventricular outflow tract (VOT) reinterventions. There were no differences from the control group in left VOT or right VOT reinterventions. Neither group showed differences between pre- and late follow-up aortic root and ascending aorta dimensions, and no correlations were found among preoperative pulmonary valve (PV) size, late aortic regurgitation (AR), aortic root, or ascending aortic Z-scores. Aortic valve size increased from discharge to late follow-up for both groups (P ≤ .05); 90% of patients at late follow-up had mild or less AR with similar distributions in severity between complex and control groups. Severity of late AR showed no correlation with preoperative PV size and is independent of it. The Ross procedure has good short-term results in simple and complex patients and should be considered in those undergoing Ross operation with biventricular conversion and DKS takedown. Moreover, native PV size should not be a contraindication for Ross procedure. [ABSTRACT FROM AUTHOR]

The Ross procedure is an important tool that offers autologous tissue repair for severe left ventricular outflow tract (LVOT) pathology. Previous reports show that risk of mortality is highest among neonates and infants. We analyzed our institutional experience within this patient cohort to identify factors that most affect clinical outcome. A retrospective chart review identified all Ross operations in neonates and infants at our institution over 27 years. The entire study population was analyzed to determine risk factors for mortality and define outcomes for survival and reintervention. Fifty-eight patients underwent a Ross operation at a median age of 63 (range, 9-156) days. Eighteen (31%) were neonates. Eleven (19%) patients died before hospital discharge. Multiple regression analysis of the entire cohort identified young age (hazard ratio [HR], 1.037; P =.0045), Shone complex (HR, 17.637; P =.009), and interrupted aortic arch with ventricular septal defect (HR, 16.01; P =.031) as independent predictors of in-hospital mortality. Receiver operating characteristic analysis (area under the curve, 0.752) indicated age younger than 84 days to be the inflection point at which mortality risk increases. Of the 47 survivors, there were 2 late deaths with a mean follow-up of 6.7 (range, 2.1-13.1) years. Three patients (6%) required LVOT reintervention at 3, 8, and 17.5 years, respectively, and 26 (55%) underwent right ventricular outflow tract reintervention at a median of 6 (range, 2.5-10.3) years. Ross procedure is effective in children less than one year of age with left sided obstructive disease isolated to the aortic valve and/or aortic arch. Patients less than 3 months of age with Shone or IAA/VSD are at higher risk for morbidity and mortality. Survivors experience excellent intermediate-term freedom from LVOT reintervention. [Display omitted] [ABSTRACT FROM AUTHOR]

To compare outcomes with wrapped (pulmonary autograft inclusion) versus unwrapped techniques in adults with bicuspid aortic valves undergoing the Ross procedure. Between 1992 and 2019, 129 adults with bicuspid aortic valves (aged ≥18 years) underwent the Ross procedure by a single surgeon. Patients were divided into those without autograft inclusion (unwrapped, n = 71) and those with autograft inclusion (wrapped, n = 58). Median follow-up was 10.3 years (interquartile range, 3.0-16.8 years). Need for autograft reintervention was analyzed using competing risks. Pre- and intraoperative characteristics as well as 30-day morbidity or mortality did not differ between cohorts. Survival at 1, 5, and 10 years, respectively, was 97.2%, 97.2%, and 95.6% in the unwrapped cohort and 100%, 100%, and 100% in the wrapped cohort (P =.15). Autograft valve failure occurred in 25 (35.2%) of the unwrapped and 3 (5.2%) of the wrapped patients. Competing risks analysis demonstrated the wrapped cohort to have a lower need for autograft reintervention (subhazard ratio, 0.28, 95% confidence interval, 0.08-0.91; P =.035). The cumulative incidence of autograft reintervention (death as a competing outcome) at 1, 5, and 10 years, respectively, was 10.2%, 14.9%, and 26.8% in the unwrapped cohort and 4.0%, 4.0%, and 4.0% in the wrapped cohort. In adults with bicuspid aortic valves, the Ross procedure with pulmonary autograft inclusion stabilizes the aortic root preventing dilatation and reduces the need for reoperation. The autograft inclusion technique allows the Ross procedure to be performed in this population with excellent long-term outcomes. A retrospective cohort study was conducted in which 129 adult patients with bicuspid aortic valves underwent the Ross procedure with either a standard root inclusion technique or a modified technique whereby the pulmonary autograft is wrapped in a vascular conduit. Primary outcomes were survival and need for pulmonary autograft reintervention. Competing risk analysis demonstrated the wrapped technique reduced pulmonary autograft reintervention. Created with www.BioRender.com. [Display omitted] [ABSTRACT FROM AUTHOR]

The Ross procedure is an excellent option for children or young adults who need aortic valve replacement because it can restore survival to that of the normal aged-matched population. However, autograft remodeling can lead to aneurysmal formation and reoperation, and the biomechanics of this process is unknown. This study investigated postoperative autograft remodeling after the Ross procedure by examining patient-specific autograft wall stresses. Patients who have undergone the Ross procedure who had intraoperative pulmonary root and aortic specimens collected were recruited. Patient-specific models (n = 16) were developed using patient-specific material property and their corresponding geometry from cine magnetic resonance imaging at 1-year follow-up. Autograft ± Dacron for aneurysm repair and ascending aortic geometries were reconstructed to develop patient-specific finite element models, which incorporated material properties and wall thickness experimentally measured from biaxial stretching. A multiplicative approach was used to account for prestress geometry from in vivo magnetic resonance imaging. Pressure loading to systemic pressure (120/80) was performed using LS-DYNA software (LSTC Inc, Livermore, Calif). At systole, first principal stresses were 809 kPa (25%-75% interquartile range, 691-1219 kPa), 567 kPa (485-675 kPa), 637 kPa (555-755 kPa), and 382 kPa (334-413 kPa) at the autograft sinotubular junction, sinuses, annulus, and ascending aorta, respectively. Second principal stresses were 360 kPa (310-426 kPa), 355 kPa (320-394 kPa), 272 kPa (252-319 kPa), and 184 kPa (147-222 kPa) at the autograft sinotubular junction, sinuses, annulus, and ascending aorta, respectively. Mean autograft diameters were 29.9 ± 2.7 mm, 38.3 ± 5.3 mm, and 26.6 ± 4.0 mm at the sinotubular junction, sinuses, and annulus, respectively. Peak first principal stresses were mainly located at the sinotubular junction, particularly when Dacron reinforcement was used. Patient-specific simulations lay the foundation for predicting autograft dilatation in the future after understanding biomechanical behavior during long-term follow-up. Of 290 patients undergoing the Ross procedure at Montreal Heart Institute, a subset of 16 patients had autograft and aortic tissue removed during surgery for biaxial stretch testing for material properties and postoperative MRI at 1 year. Patient-specific modeling of pulmonary autografts were performed using 3-dimensional patient-specific imaging and material properties. FEAs were performed to determine wall stresses in the autograft and ascending aorta. The pulmonary autograft had significantly higher wall stresses than the distal ascending aorta (native internal control), which could drive remodeling over time. Future clinical follow-up can provide understanding of autograft biomechanics in relation to clinical dilatation. [Display omitted] [ABSTRACT FROM AUTHOR]

Background Autograft valve preservation at reoperation may conserve some of the advantages of the Ross procedure. However, results of long-term follow-up are lacking. In this retrospective multicenter study, we present our experience with valve-sparing reoperations after the Ross procedure, with a focus on long-term outcome. Methods A total of 86 patients from 6 European centers, who underwent valve-sparing reoperation after the Ross procedure between 1997 and 2013, were included in the study. Results Reoperation was performed a median of 9.1 years after the Ross procedure in patients with a median age of 38.4 years (interquartile range: 27.1-51.6 years). Preoperative severe autograft regurgitation (grade ≥3) was present in 46% of patients. In-hospital mortality was 1%. During a median follow-up of 4.3 years, 3 more patients died of noncardiac causes, resulting in a cumulative survival at 8 years of 89% (95% confidence interval: 65%-97%). Fifteen patients required a reintervention after valve-sparing reoperation, mostly owing to prolapse or retraction of autograft cusps. Freedom from reintervention was 76% (95% confidence interval: 57%-87%) at 8 years. The reintervention hazard was increased in patients who had isolated and/or severe aortic regurgitation at valve-sparing reoperation. In patients without reintervention after valve-sparing autograft reoperation (n = 63), severe aortic regurgitation was present in 3% at last follow-up. Conclusions Valve-sparing autograft reoperations after the Ross procedure carry a low operative risk, with acceptable reintervention rates in the first postoperative decade. Patients with isolated and/or severe autograft regurgitation have an increased hazard of reintervention after valve-sparing reoperation; for these patients, careful preoperative weighing of surgical options is required. [ABSTRACT FROM AUTHOR]

The Ross procedure offers several advantages in nonelderly adults; however, the optimal age cutoff remains undetermined. The aim of this study was to compare the safety and mid-term outcomes after the Ross procedure in adult patients age ≤50 years and those age >50 years. Between 2011 and 2019, 497 consecutive patients (mean age, 47 ± 12 years; 73% male) underwent a Ross procedure in 5 Canadian centers and were followed prospectively. Of these patients, 232 (47%) were age >50 years (mean, 57 ± 4 years) and 265 (53%) were age ≤50 years (mean, 38 ± 10 years). Early and mid-term outcomes were compared between the 2 groups. Patients age >50 years had more comorbidities: diabetes (14% vs 4%; P <.01), chronic obstructive pulmonary disease (8% vs 2%; P <.01), and coronary artery disease (17% vs 3%; P <.01). In contrast, patients age ≤50 years had more redo surgeries (24% vs 8%; P <.01), pure aortic regurgitation (21% vs 6%; P <.01) and unicuspid valves (42% vs 9%; P <.01). In-hospital mortality was similar in the 2 groups (0.4% vs 0.4%; P =.99). There were no between-group differences in perioperative complications. The cumulative incidence of reintervention was similar at 6 years (>50 years: 0.7 ± 0.7%; ≤50 years: 4 ± 2%; P =.12). Survival at 6 years was 98 ± 2% in patient age >50 years versus 96 ± 2% in those age ≤50 years (P =.43), similar to the age- and sex-matched general population. The Ross procedure is a safe operation in patients age >50 years and provides excellent hemodynamics, stable valve function, and restored survival at mid-term follow-up. In expert centers, it should be considered as an alternative in selected patients age >50 years. [Display omitted] [ABSTRACT FROM AUTHOR]

Young patients who underwent the Ross procedure recorded high rates of survival and low rates of reintervention long term. [ABSTRACT FROM AUTHOR]

Abstract: Several disease pathologies such as congenital heart disease and rheumatic fever can affect the aortic valve (AV) in children frequently necessitating intervention. While percutaneous or surgical AV repair is recommended as initial management strategy in children with AV disease, AV replacement (AVR) might become necessary in children with significant valve destruction and after repair or intervention failure. AVR in children is associated with distinct clinical and technical problems owing to several anatomic, social and prosthesis-related issues. In the current review, we list different AV substitutes, discuss their advantages and shortcomings, outline AVR results in children, and explore the divergence of outcomes in various age, anatomy and pathology subgroups; all in the aim to identify optimal AVR choice for each patient taking into consideration his unique anatomic and demographic characteristics. [Copyright &y& Elsevier]

Transcatheter (percutaneous) pulmonary valve (TPV) replacement has emerged as a viable therapy for right ventricular outflow tract conduit dysfunction. Little is known about the incidence, clinical course, and outcome of infective endocarditis (IE) after TPV implant. We reviewed combined data from 3 ongoing prospective multicenter trials to evaluate the experience with IE among patients undergoing TPV replacement using the Melody valve.Any clinical episode reported by investigators as IE with documented positive blood cultures and fever, regardless of TPV involvement, was considered IE. Cases were classified as TPV-related if there was evidence of vegetations on or new dysfunction of the TPV. The 3 trials included 311 patients followed for 687.1 patient-years (median, 2.5 years). Sixteen patients were diagnosed with IE 50 days to 4.7 years after TPV implant (median, 1.3 years), including 6 who met criteria for TPV-related IE: 3 with vegetations, 2 with TPV dysfunction, and 1 with both. The annualized rate of a first episode of IE was 2.4% per patient-year and of TPV-related IE was 0.88% per patient-year. Freedom from TPV-related IE was 97±1% 4 years after implant. All patients were treated with intravenous antibiotics, 4 had the valve explanted, and 2 received a second TPV. There was 1 sepsis-related death, 1 patient died of sudden hemoptysis, and 2 patients developed recurrent IE.Bacterial endocarditis has occurred in all 3 prospective multicenter studies of the Melody valve in North America and Europe. Most cases did not involve the TPV and responded to antibiotics. More data are necessary to understand risk factors in this population.URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00740870, NCT01186692, and NCT00688571. [ABSTRACT FROM AUTHOR]

Copyright of West Indian Medical Journal is the property of West Indian Medical Journal (WIMJ) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The purpose of this paper is to review the current literature and practice of the Ross concept of using the autologous pulmonary valve to replace a diseased aortic valve. The potential advantages and disadvantages of these operations will be evaluated in the context of alternative options and relative risks. The different surgical techniques of subcoronary and full root methods will be discussed and important technical aspects reviewed. Long-term outcomes will be described to the extent these are available, including recent publications describing a survival advantage for the Ross. Brief discussions will be presented regarding hemodynamics, child-bearing, endocarditis, and the use of the Ross in pediatric patients as well as biological adaptability of the living pulmonary autograft. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: We report a case of a patient with congenital aortic stenosis previously repaired using the Ross procedure, who presented to our unit for urgent caesarean delivery. Management was complicated by moderate residual cardiac disease and the presence of a suprapubic femoro-femoral crossover graft. Following application of five-lead electrocardiogram and invasive blood pressure monitoring, anaesthesia was induced via combined spinal-epidural with epidural volume extension. A high transverse surgical approach avoided the course of the vascular graft, while further precautions included the immediate availability of vascular surgeons and cell salvage. Our anaesthetic technique was tailored to minimise disruption to cardiovascular function, and in particular to limit regurgitant flow across the pulmonary valve. This case highlights the value of early identification of high-risk parturients and multidisciplinary involvement at delivery. Risk stratification in the patient with grown-up congenital heart disease is based upon timely evaluation of the underlying congenital pathology, surgical history and subsequent functional status. [Copyright &y& Elsevier]

Pulmonary homograft dysfunction is a limitation after the Ross procedure. Decellularized pulmonary homografts can potentially mitigate this complication. The aim of this study was to examine the incidence, predictors, progression, and morphology of pulmonary homograft dysfunction using data from the Canadian Ross Registry. From 2011 to 2019, 466 consecutive patients (mean age: 47 ± 12 years, 73% male) underwent a Ross procedure using a decellularized cryopreserved pulmonary homograft (SynerGraft SG; CryoKife, Kennesaw, Ga). Pulmonary homograft dysfunction was defined as any of the following: peak pulmonary gradient ≥30 mm Hg, pulmonary regurgitation >2, or pulmonary homograft reintervention. Patients meeting ≥1 of these criteria (n = 30) were compared with the rest of the cohort (n = 436). Median follow-up is 2.2 years (maximum = 8.5 years) and 99% complete (1176 patient-years). The cumulative incidence of pulmonary homograft dysfunction was 11 ± 2% at 6 years. Pulmonary homograft stenosis was the most frequent presentation (n = 28 patients, 93%). Morphologically, stenosis occurred most often along the conduit (59%). Overall, 4 patients required homograft reintervention. At 6 years, the cumulative incidence of homograft reintervention was 3 ± 1%. The instantaneous risk was greatest in the first year after surgery (3.5%/year) and decreased to <1%/year thereafter. Patient age <45 years was the only independent risk factor associated with pulmonary homograft dysfunction (hazard ratio, 3.1, 95% confidence interval, 1.1-8.6, P =.03). The use of decellularized cryopreserved pulmonary homografts results in a low incidence of dysfunction and reintervention after the Ross procedure. The risk is greater in the first postoperative year. Younger age is the only independent risk factor for pulmonary homograft dysfunction. [Display omitted] [ABSTRACT FROM AUTHOR]

Difficult to repair aortic valve lesions, requiring the use of a valve substitute, remain controversial in the face of the Ross procedure, despite undeniable technical advances. This study was undertaken to compare midterm outcomes of children treated using the Ross procedure or aortic valvuloplasty for complex aortic valve lesions. Between January 2006 and December 2017, 126 patients aged younger than 18 years were treated for complex aortic stenosis and/or aortic insufficiency and were included in this retrospective study. Only aortic valve lesions requiring repair with an autologous or heterologous pericardial patch were considered complex lesions. Propensity score framework analyses were used to compare outcomes of the Ross and aortic valvuloplasty groups while controlling for confounders. Among the 126 patients with complex aortic valve lesions, propensity score matching selected 34 unique pairs of patients with similar characteristics. Survival (aortic valvuloplasty, 94.1%; Ross, 91%; P =.89), freedom from overall reintervention (aortic valvuloplasty, 50.1%; Ross, 69%; P =.32), and freedom from infective endocarditis at 8 years (aortic valvuloplasty, 100%; Ross, 85.9%; P =.21) were similar. However, freedom from reintervention in the left ventricular outflow tract at 8 years was lower after aortic valvuloplasty than after the Ross procedure (50.1% vs 100%, respectively; P =.001). Aortic valvuloplasty and the Ross procedure yielded similar 8-year outcomes regarding death, reoperation, and infective endocarditis although aortic valvuloplasty tended to be associated with fewer cases of infective endocarditis. Aortic valvuloplasty using a pericardial patch can be chosen as a first-line strategy for treating complex aortic valve lesions and might offer the possibility of a later Ross procedure. Kaplan–Meier freedom from overall reoperation and freedom from reoperation in the left ventricular outflow tract (LVOT) in the propensity-matched populations who received aortic valvuloplasty or the Ross procedure. Adjusted freedom from reintervention was 69% in patient who received the Ross procedure, and 50.1% for patients with complex aortic valve repair at 8 years. However, indication for reintervention was different for the 2 techniques. The Ross procedure group had a lower incidence of reoperation on the LVOT compared with the aortic valvuloplasty group. The Ross procedure is clearly superior in terms of limiting the number of operations on the aortic valve, but the trade-off is the increased need for reoperation on the pulmonary conduit. [Display omitted] [ABSTRACT FROM AUTHOR]

Studies suggest that patients undergoing the Ross procedure for aortic insufficiency are at greater risk of autograft dilatation than those with aortic stenosis. By using a tailored Ross technique to mitigate autograft dilatation in patients with aortic insufficiency, we aimed to compare the biomechanical and morphologic remodeling of the autograft at 1 year between patients with aortic insufficiency and patients with aortic stenosis. A total of 210 patients underwent a Ross procedure (2011-2016). Of those, 86 patients (mean age 43 ± 13 years; 32% were female) completed preoperative and postoperative cardiovascular magnetic resonance imaging. A total of 71 studies were suitable for analysis: 41 patients with aortic stenosis and 30 patients with aortic insufficiency. Nine healthy adults were used as controls. Autograft root dimensions, individual sinus volumes, and distensibility were measured using cardiovascular magnetic resonance. At 1 year, there was no difference in autograft root dimensions between patients with aortic stenosis (mean annulus 25.1 ± 3.1 mm and sinus diameters 35 ± 4.1 mm) and patients with aortic insufficiency (26.6 ± 3 mm and 37.1 ± 3.5 mm; P =.12 and.06, respectively). Relative sinus of Valsalva volumes were symmetrical in the aortic stenosis (right 34.8% ± 4%, left 33.7% ± 3.5%, noncoronary 31.4% ± 3.2%) and aortic insufficiency groups (34.8% ± 3.9%, 33.8% ± 2.8%, 31.3% ± 3.7%, P =.85,.92, and.82), and similar to those of healthy adults. Aortic root distensibility was reduced in both groups compared with healthy adults (P =.003), but was similar between aortic stenosis (3.12 ± 1.58 × 10−3 mm Hg−1) and aortic insufficiency (3.04 ± 1.15 × 10−3 mm Hg−1; P =.9). Using a tailored technique, there were no differences in the morphologic or biomechanical remodeling of the autograft root 1 year after the Ross procedure between patients with aortic stenosis and patients with aortic insufficiency. However, autograft roots are stiffer than native aortic roots. We compared the biomechanical and morphologic remodeling of the autograft at 1 year among patients with AI, patients with AS, and healthy controls. Among 210 patients (2011-2016) who underwent the Ross procedure, 71 (41 with AS and 30 with AI) had cardiovascular CMR studies fit for analysis. Healthy adults were used as controls. At 1 year, those undergoing the Ross procedure had slightly dilated and stiffer autograft roots compared with the aortic root in healthy controls. Sinuses of Valsalva volumes were homogenously distributed among the left, right, and noncoronary sinuses in autograft roots. There were no substantial differences in autograft root size, distensibility, and geometry between patients with AS and AI. [Display omitted] [ABSTRACT FROM AUTHOR]

Summary: We report the morphological changes in a patient with combined pulmonary autograft and homograft dysfunction after 9 years of implantation. The case highlights long-term adaptive changes in the autograft to withstand systemic blood pressure with formation of exuberant pannus rich in elastic tissue. In the homograft, maturation of pannus had produced shortening of the 3 cusps with resultant incompetence. [Copyright &y& Elsevier]

Dilatation of the pulmonary autograft is a problem described following Ross procedure for aortic valve replacement. Patients at risk seem to be those with aortic insufficiency, bicuspid aortic valves, and those with aneurismal ascending aortas. We describe a technique for encasing the pulmonary autograft in a Dacron tube to prevent dilatation in these patients. This technique is reproducible and includes sewing the coronary arteries to all layers of the autograft and Dacron construct. Short-term follow-up shows excellent outcomes with respect to autograft valve function and lack of annular or sinotubular dilatation. This procedure may be useful for extending the Ross procedure to young adults, where autograft growth is no longer needed, to provide a non-dilatable neoaortic root. [Copyright &y& Elsevier]