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During the Ross procedure, an aortic heart valve is replaced by a patient's own pulmonary valve. The pulmonary autograft subsequently undergoes substantial growth and remodeling (G&R) due to its exposure to increased hemodynamic loads. In this study, we developed a homogenized constrained mixture model to understand the observed adaptation of the autograft leaflets in response to the changed hemodynamic environment. This model was based on the hypothesis that tissue G&R aims to preserve mechanical homeostasis for each tissue constituent. To model the Ross procedure, we simulated the exposure of a pulmonary valve to aortic pressure conditions and the subsequent G&R of the valve. Specifically, we investigated the effects of assuming either stress- or stretch-based mechanical homeostasis, the use of blood pressure control, and the effect of root dilation. With this model, we could explain different observations from published clinical studies, such as the increase in thickness, change in collagen organization, and change in tissue composition. In addition, we found that G&R based on stress-based homeostasis could better capture the observed changes in tissue composition than G&R based on stretch-based homeostasis, and that root dilation or blood pressure control can result in more leaflet elongation. Finally, our model demonstrated that successful adaptation can only occur when the mechanically induced tissue deposition is sufficiently larger than tissue degradation, such that leaflet thickening overrules leaflet dilation. In conclusion, our findings demonstrated that G&R based on mechanical homeostasis can capture the observed heart valve adaptation after the Ross procedure. Finally, this study presents a novel homogenized mixture model that can be used to investigate other cases of heart valve G&R as well. [ABSTRACT FROM AUTHOR]

Objective: In our study, we aim to explore the structural differences between the aortic root and the pulmonary artery to better understand the process of pulmonary autograft dilatation during the Ross procedure. Materials and methods: We studied twenty human fetuses (aged 14–36 weeks of gestation) and four adults (one female and three males, aged 30–45 years, mean age = 37 ± 16 years). Samples of aortic root and pulmonary artery were obtained through dissection. Histological examinations, including hematoxylin–eosin, Masson's trichrome, and orcein staining, as well as immunohistochemical technique with caldesmon staining, were performed. Microscopic counting was conducted to assess the number of elastic laminae and smooth muscle cells in each arterial wall. Statistical analyses were performed using R software. Means and standard deviations were used to present central tendencies and data dispersion for elastic laminae and smooth muscle. Results: Significant histological differences were observed between the aortic root and pulmonary artery in both adults and fetuses. In fetuses, no difference was found between the two vessels in terms of elastic laminae (p = 0.26) and smooth muscle cells (p = 0.69). However, in adults, significant differences were found for elastic laminae (p < 0.001) and smooth muscle cells (p < 0.001) between the aorta and pulmonary artery. Conclusions: The microscopic vascular structure impacts the mechanical properties of the pulmonary autograft wall and explains its observed dilatation remote from the Ross procedure due to wall stresses related to systemic pressure. [ABSTRACT FROM AUTHOR]

Background: Congenital aortic valve (AV) disease is viewed in 2% of the population and in 20 out of 1000 neonates are presented with bicuspid configuration. Treatment of the congenital AV diseases requires multiple interventions. The ultimate goal is to provide adequate close to physiological left ventricle outflow and minimization of regurgitation. The optimal operative management of AV disease in children and young adults remains controversial. AV neocuspidization with glutaraldehyde‐treated autologous pericardium may be a satisfactory alternative in pediatric cardiac surgery. Objectives: The data of the AVNeo procedure results enable a comparative analysis of various AV reconstructive approaches in the pediatric cohort. In this article, we present the comparative study of various techniques in pediatric AV surgery, including the immediate and midterm outcomes of AVNeo, commissurotomy with aortic leaflet augmentation using pericardial patch ("free style" technique), and Ross procedure. Study Design: We conducted a retrospective analysis of the early and midterm results of surgical AV disease treatment of 44 children in 5 cardiac surgery centers from 2014 to 2022. The patients were divided into 3 groups: group I: glutaraldehyde‐treated autologous pericardium AVNeo (n = 12), group II: "free style" technique (n = 10), and group III: Ross procedure (n = 22). We described the immediate and midterm outcomes. The study design was approved by the ethics committees of the participating centers. Results: A total of 44 children after surgical treatment of the AV disease in 5 cardiac surgery centers were included in the study and were grouped as group I: AVNeo (n = 12), group II: "free style" technique (n = 10), and group III: Ross procedure (n = 22). The median follow‐up period was 57 ± 23.8 months. In‐hospital mortality was 4.5% (n = 2). In the midterm follow‐up, the peak pressure gradient was 18.45 ± 4.63 mmHg for group I and 8.9 ± 1.6 mmHg for group III (p = 0.00001), respectively. The cumulative freedom from reoperations was 100%, 30%, and 95.2% for 40 months of follow‐up and 100%, 30%, and 83.4% for 70 months of follow‐up in I, II, and III groups, respectively. No cases of midterm mortality were detected in all groups. Conclusion: The AV neocuspidization with glutaraldehyde‐treated autologous pericardium has an enormous advantage in pediatric AV surgery, significantly surpassing the freedom from resurgery of repair procedures and having comparable results with the Ross procedure in the midterm follow‐up. [ABSTRACT FROM AUTHOR]

Abstract Objective In our study, we aim to explore the structural differences between the aortic root and the pulmonary artery to better understand the process of pulmonary autograft dilatation during the Ross procedure. Materials and methods We studied twenty human fetuses (aged 14–36 weeks of gestation) and four adults (one female and three males, aged 30–45 years, mean age = 37 ± 16 years). Samples of aortic root and pulmonary artery were obtained through dissection. Histological examinations, including hematoxylin–eosin, Masson’s trichrome, and orcein staining, as well as immunohistochemical technique with caldesmon staining, were performed. Microscopic counting was conducted to assess the number of elastic laminae and smooth muscle cells in each arterial wall. Statistical analyses were performed using R software. Means and standard deviations were used to present central tendencies and data dispersion for elastic laminae and smooth muscle. Results Significant histological differences were observed between the aortic root and pulmonary artery in both adults and fetuses. In fetuses, no difference was found between the two vessels in terms of elastic laminae (p = 0.26) and smooth muscle cells (p = 0.69). However, in adults, significant differences were found for elastic laminae (p

OBJECTIVES The potential risk of autograft dilatation and homograft stenosis after the Ross procedure mandates lifelong follow-up. This retrospective cohort study aimed to determine long-term outcome of the Ross procedure, investigating autograft and homograft failure patterns leading to reintervention. METHODS All adults who underwent the Ross procedure between 1991 and 2018 at the University Hospitals Leuven were included, with follow-up data collected retrospectively. Autograft implantation was performed using the full root replacement technique. The primary end-point was long-term survival. Secondary end-points were survival free from any reintervention, autograft or homograft reintervention-free survival, and evolution of autograft diameter, homograft gradient and aortic regurgitation grade over time. RESULTS A total of 173 adult patients (66% male) with a median age of 32 years (range 18–58 years) were included. External support at both the annulus and sinotubular junction was used in 38.7% (67/173). Median follow-up duration was 11.1 years (IQR, 6.4–15.9; 2065 patient-years) with 95% follow-up completeness. There was one (0.6%) perioperative death. Kaplan–Meier estimate for 15-year survival was 91.1% and Ross-related reintervention-free survival was 75.7% (autograft: 83.5%, homograft: 85%). Regression analyses demonstrated progressive neoaortic root dilatation (0.56 mm/year) and increase in homograft gradient (0.72 mmHg/year). CONCLUSIONS The Ross procedure has the potential to offer excellent long-term survival and reintervention-free survival. These long-term data further confirm that the Ross procedure is a suitable option in young adults with aortic valve disease which should be considered on an individual basis. [ABSTRACT FROM AUTHOR]

Abstract Background The Ross procedure is a technically complex operation to address the pathology of the aortic valve. Prior attempts at widespread implementation have been plagued with variations in effectiveness. We report our initial programmatic outcomes using dissemination and implementation (D&I) science frameworks, with an aim to define both programmatic efficacy and effectiveness. The study design was a single center, explanatory sequential mixed methods evaluation of a Ross surgery program from June 2020 to April 2023. Quantitative measures for baseline patient characteristics and postoperative outcomes were summarized. Qualitative measures were obtained using semi-structured interviews and characterized using implementation science frameworks. Results A total of 71 patients underwent the Ross procedure at a single academic center. Mean age was 40 years (± 13). There were no perioperative deaths or valve-related reinterventions (0%). During the follow-up period, 2 (2.8%) patients required re-operation and 2 (2.8%) required balloon dilation of the pulmonary homograft. Qualitative measures noted communication and prospective self-audit facilitated measures of effectiveness, as dichotomy within expected vs. observed outcomes led to program modifications. Collaboration across hospital systems promoted adoption and implementation, which led to the incorporation of the Ross procedure into accepted organizational practice. Conclusions In this formative evaluation, limited-efficacy outcomes demonstrated similar programmatic success to data from other established centers. With the prerequisite center volume and case selection, the Ross procedure is a safe and efficacious treatment for aortic valvular disease. Implementation science can be used both in real-time and retrospectively to guide organizational efforts to improve outcomes and to improve the translation of results across centers.

Background: The Ross procedure is a technically complex operation to address the pathology of the aortic valve. Prior attempts at widespread implementation have been plagued with variations in effectiveness. We report our initial programmatic outcomes using dissemination and implementation (D&I) science frameworks, with an aim to define both programmatic efficacy and effectiveness. The study design was a single center, explanatory sequential mixed methods evaluation of a Ross surgery program from June 2020 to April 2023. Quantitative measures for baseline patient characteristics and postoperative outcomes were summarized. Qualitative measures were obtained using semi-structured interviews and characterized using implementation science frameworks. Results: A total of 71 patients underwent the Ross procedure at a single academic center. Mean age was 40 years (± 13). There were no perioperative deaths or valve-related reinterventions (0%). During the follow-up period, 2 (2.8%) patients required re-operation and 2 (2.8%) required balloon dilation of the pulmonary homograft. Qualitative measures noted communication and prospective self-audit facilitated measures of effectiveness, as dichotomy within expected vs. observed outcomes led to program modifications. Collaboration across hospital systems promoted adoption and implementation, which led to the incorporation of the Ross procedure into accepted organizational practice. Conclusions: In this formative evaluation, limited-efficacy outcomes demonstrated similar programmatic success to data from other established centers. With the prerequisite center volume and case selection, the Ross procedure is a safe and efficacious treatment for aortic valvular disease. Implementation science can be used both in real-time and retrospectively to guide organizational efforts to improve outcomes and to improve the translation of results across centers. [ABSTRACT FROM AUTHOR]

Objective(s): Identifying the optimal solution for young adults requiring aortic valve replacement (AVR) is challenging, given the variety of options and their lifetime complication risks, impacts on quality of life, and costs. Decision analytic techniques make comparisons incorporating these measures. We evaluated lifetime valve-related outcomes of mechanical aortic valve replacement (mAVR) versus the Ross procedure (Ross) using decision tree microsimulations modeling. Methods: Transition probabilities, utilities, and costs derived from published reports were entered into a Markov model decision tree to explore progression between health states for hypothetical 18-year-old patients. In total, 20,000 Monte Carlo microsimulations were performed to model mortality, quality-adjusted-life-years (QALYs), and health care costs. The incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analyses was performed to identify transition probabilities at which the preferred strategy switched from baseline. Results: From modeling, average 20-year mortality was 16.3% and 23.2% for Ross and mAVR, respectively. Average 20-year freedom from stroke and major bleeding was 98.6% and 94.6% for Ross, and 90.0% and 82.2% for mAVR, respectively. Average individual lifetime (60 postoperative years) utility (28.3 vs 23.5 QALYs) and cost ($54,233 vs $507,240) favored Ross over mAVR. The average ICER demonstrated that each QALY would cost $95,345 more for mAVR. Sensitivity analysis revealed late annual probabilities of autograft/left ventricular outflow tract disease and homograft/right ventricular outflow tract disease after Ross, and late death after mAVR, to be important ICER determinants. Conclusions: Our modeling suggests that Ross is preferred to mAVR, with superior freedom from valve-related morbidity and mortality, and improved cost-utility for young adults requiring aortic valve surgery.

Open in new tab Download slide OBJECTIVES The Ross procedure represents an excellent treatment option in younger patients with aortic stenosis but is limited by poor availability of homografts. In this study, we investigated the hydrodynamic performance of 3 different types of right ventricular outflow tract replacement with pericardium or synthetic material. METHODS Three different types of valved conduits were constructed using pericardium and/or synthetic material (Group PEPE: pericardial cusps and pericardial conduit, Group PEPR: pericardial cusps and Dacron conduit, Group PRPR: expanded polytetrafluoroethylene cusps and Dacron conduit). The conduits were designed according to the Ozaki method. Their hydrodynamic performance (effective orifice area, mean pressure gradient and leakage volume) were evaluated in a mock circulation loop at different hydrodynamic conditions. RESULTS Hydrodynamic assessment showed significantly larger effective orifice area of PEPE and PEPR compared to PRPR under all conditions and there were no significant differences between PEPE and PEPR [for condition 2: PEPE 2.43 (2.35–2.54) cm2, PEPR: 2.42 (2.4–2.5) cm2, PRPR: 2.08 (1.97–2.21) cm2, adjusted pairwise comparisons: PEPE versus PEPR: P  = 0.80, PEPE versus PRPR: P  < 0.001, PEPR versus PRPR: P  < 0.001]. Mean pressure gradient was significantly lower for PEPE and PEPR compared with PRPR, whereas no significant differences were seen between PEPE and PEPR. Leakage volume was significantly lower for PEPE and PEPR compared with PRPR under all conditions while leakage was similar between PEPE and PEPR. CONCLUSIONS Pulmonary graft reconstruction with pericardium cusps showed superior hydrodynamic performance compared with polytetrafluoroethylene cusps. Our results suggest that it could be considered as an alternative substitute for right ventricular outflow tract replacement during the Ross procedure. [ABSTRACT FROM AUTHOR]

The Ross procedure is gaining recognition as a significant option for aortic valve replacement (AVR), and is particularly beneficial in specific patient groups. Although categorized as a class IIb recommendation in the 2020 American College of Cardiology (ACC)/American Heart Association (AHA), and the European Society of Cardiology (ESC) management guidelines on valvular heart disease, recent studies bolster its credibility. Research, including a propensity-matched study, underlines the Ross procedure's association with enhanced long-term survival and reduced adverse valve-related events compared to other AVR types. This positions the Ross procedure as a primary option for AVR in young and middle-aged adults within specialized centers, and potentially the only choice for children and infants requiring AVR. This review meticulously examines the Ross procedure, covering historical perspectives, surgical techniques, imaging, and outcomes, including hemodynamic performance and quality of life, especially focusing on pediatric and young adult patients. It explores contemporary techniques and innovations like minimally invasive approaches and tissue engineering, underscoring ongoing research and future directions. A summarization of comparative studies and meta-analyses reiterates the Ross procedure's superior long-term outcomes, valve durability, and preservation of the left ventricular function, accentuating the crucial role of patient selection and risk stratification, and pinpointing areas for future research. [ABSTRACT FROM AUTHOR]

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]

Abstract Background The science of dissemination and implementation (D&I) aims to improve the quality and effectiveness of care by addressing the challenges of incorporating research and evidence-based practice into routine clinical practice. This lens of D&I has challenged the interpretation and incorporation of data, noting that failure of a given therapy may not reflect lack of efficacy, but instead reflect an imperfect implementation. The aim of this manuscript is to review the influence of the Ross procedure’s historical context on its D&I. Methods A contextual baseline of the Ross procedure was defined from the procedure’s original description in the literature to major publications since the 2017 valvular heart disease guidelines. D&I evaluation was conducted using the Consolidated Framework for Implementation Research (CFIR), using constructs from each of the five respective domains to define the main determinants. Results Each of the five CFIR domains appears to be correlated with a factor influencing the Ross procedure’s varied history of enthusiasm and acceptance. The complex nature of Ross required adaptation for optimization, with a strong correlation of center volume on outcomes that were not considered in non-contemporary studies. Outcomes later published from those studies influenced social and cultural contexts within the aortic surgery community, and led to further organizational uncertainty, resulting in slow guideline incorporation. Conclusions The D&I of the Ross procedure was a result of inadequate appreciation of technical complexity, effect of patient selection, and complex aortic surgery experience, resulting in dismissal of an efficacious procedure due to a misunderstanding of effectiveness.

Pure aortic regurgitation and dilation of aortic annulus are the most significant risk factors for the failure of pulmonary autograft after the Ross procedure. Aortic annuloplasty has a positive effect on the durability of the autograft. Previously, we described a technique for external annuloplasty with dedicated CORONEO ring. In the present manuscript, we suggest the sizing of annuloplasty based on the diameter of pulmonary autograft annulus. [ABSTRACT FROM AUTHOR]

Abstract 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.

Background: The science of dissemination and implementation (D&I) aims to improve the quality and effectiveness of care by addressing the challenges of incorporating research and evidence-based practice into routine clinical practice. This lens of D&I has challenged the interpretation and incorporation of data, noting that failure of a given therapy may not reflect lack of efficacy, but instead reflect an imperfect implementation. The aim of this manuscript is to review the influence of the Ross procedure's historical context on its D&I. Methods: A contextual baseline of the Ross procedure was defined from the procedure's original description in the literature to major publications since the 2017 valvular heart disease guidelines. D&I evaluation was conducted using the Consolidated Framework for Implementation Research (CFIR), using constructs from each of the five respective domains to define the main determinants. Results: Each of the five CFIR domains appears to be correlated with a factor influencing the Ross procedure's varied history of enthusiasm and acceptance. The complex nature of Ross required adaptation for optimization, with a strong correlation of center volume on outcomes that were not considered in non-contemporary studies. Outcomes later published from those studies influenced social and cultural contexts within the aortic surgery community, and led to further organizational uncertainty, resulting in slow guideline incorporation. Conclusions: The D&I of the Ross procedure was a result of inadequate appreciation of technical complexity, effect of patient selection, and complex aortic surgery experience, resulting in dismissal of an efficacious procedure due to a misunderstanding of effectiveness. [ABSTRACT FROM AUTHOR]

This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES There are several treatment options for non-elderly adults (18–60 years) in need of aortic valve replacement (AVR): a mechanical or biological substitute, a homograft, the Ross procedure or nowadays even transcatheter aortic valve replacement. This study evaluated the current opinions and practices of cardiac surgeons and cardiologists concerning AVR strategies in this patient group. METHODS A 43-item online survey was sent out to several scientific organizations, individual cardiac surgeons, cardiologists and residents/fellows worldwide. RESULTS Two hundred twenty-two physicians from 33 different countries answered the survey. The UK (24%), Belgium (23%) and North America (22%) are best represented. A mechanical valve is the most frequently used substitute in non-elderly. With increasing patient age, the popularity of a biological valve increases. Transcatheter aortic valve replacement and the Ross procedure are each used in <10% of this cohort. Only 12% of the cardiac surgeons has experience with the Ross surgery. In 23%, the patient seems not to be involved in the decision on the type of valve substitute. CONCLUSIONS The preferred surgical treatment for non-elderly patients in need of AVR differs widely. To enable a shared decision-making process including patient preferences, there is more need for collaboration between cardiac departments, as well as education and scientific research about patient-centred outcomes of the different AVR techniques. [ABSTRACT FROM AUTHOR]

Background: The importance of pulmonary artery pressure recovery (PR) in patients with Ross procedures in whom a homograft substitutes the resected pulmonary valve, is unknown. The aim of the study was to evaluate the occurrence and extent of PR in the pulmonary artery in 65 asymptomatic patients with pulmonary homograft after Ross surgery during rest and exercise. Methods: Stress echocardiography was performed in 65 pulmonary homograft patients and 31 controls with native pulmonary valves up to 75 W. Right ventricular systolic pressure (RVSP), transvalvular flow, mean pressure gradient (Pmean), valve resistance, and RV stroke work were determined in the exercise (max. 75 W) and recovery phases in increments of 25 W each. Results: Pulmonary homografts demonstrated significantly elevated Pmean compared to controls at all stages. When considering pressure recovery (absolute and relative PR at rest 3.8 ± 1.8 mm Hg, 42.6 ± 7.2%, respectively) and transvalvular energy loss (EL; at rest 4.5 ± 4.3 mm Hg) the homograft hemodynamics reached the level of controls. In a subgroup of patients with tricuspid regurgitation, resting RVSP was the same in homograft patients and controls (21.3 ± 6.1 vs. 20.4 ± 6.3, p =.62), despite significant different Pmax values. Conclusions: Ross patients with pulmonary homograft showed systematically increased hemodynamic parameters compared to normal pulmonary valves. These differences were abolished when PR was considered for homograft patients. The equality of RVSP values at rest in both groups shows non‐invasive evidence for PR in the pulmonary system after homograft implantation. Therefore, PR appears to be an important measure in calculating the actual hemodynamics in pulmonary homografts. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The Ross procedure is traditionally considered for young adult patients with aortic valve disease. This study compares long-term outcomes of patients undergoing the Ross procedure who are ≥50 and <50-years old. METHODS Data were collected from 225 patients undergoing Ross procedure at a single centre from 1994 to 2019. Patients were categorized into younger (<50-years old; n  = 156) and older (≥50-years old; n  = 69) cohorts. Baseline demographics clinical outcomes were compared. RESULTS The mean age was 36 ± 8.1 and 55 ± 4.2 years in the younger and older cohort, respectively. Both groups were predominantly male (58.5% vs 69.6%; P  = 0.59). The younger group had a higher rate of aortic insufficiency (51% vs 26.1%; P  < 0.01), and bicuspid aortic valve (81.4% vs 58.0%; P  < 0.01). Aortic stenosis was more prevalent in the older cohort (25.6% vs 58.0%; P  < 0.01). Operative mortality was acceptable in both groups (1.3% vs 4.3%; P  = 0.15). Survival up to 10 years was not statistically different between 2 groups (96.2% vs 91.3% P  = 0.16), whereas survival up to 15 years for younger patients was significantly higher (94.9% vs 85.5%; P  = 0.03). After non-cardiac related deaths were excluded, survival up to 15 years (98.7% vs 91.3%; P  = 0.02) was significantly lower than younger patients. In both groups, survival after the Ross procedure was similar to the age- and sex-matched US population. CONCLUSIONS Survival up to 10 years after Ross procedure were similar, but up to 15 years was significantly higher in younger patients. The Ross procedure restored patients from both groups to expected survival. Our results suggest that at experienced centres, the Ross procedure is a safe and reasonable option for patients who are 50 years and older. [ABSTRACT FROM AUTHOR]

We report on a 6-year-old girl (18 kg/120 cm) who was diagnosed on day 6 postoperative with an occlusive thrombosis of a right ventricle-to-pulmonary artery conduit in the setting of a Ross procedure that was performed for severe native aortic valve insufficiency secondary to late diagnosis of bacterial endocarditis. We applied the Indigo® aspiration system from Penumbra® (Alameda, USA) to mechanically dissolve and remove the thrombus, restore flow, gradually wean from extracorporeal support, and replace the conduit after 4 days. The patient experiences good surgical outcomes at 3 months of follow-up. [ABSTRACT FROM AUTHOR]

BackgroundDespite numerous advantages of the Ross procedure, it presents a risk of late autograft and right ventricular outflow tract conduit failure. This study aimed to analyze the outcomes of autograft dysfunction reoperations using autograft-sparing and root replacement techniques.MethodsBetween 2015 and 2023, 49 patients underwent redo root surgery in our institution. Autograft valve-sparing procedures (VSP) were performed in 20 cases and the Bentall procedure (BP) in 29 patients. The short and long-term clinical outcomes along with echocardiographic results of VSP and BP were investigated.ResultsOverall early mortality rate was 2.0% with no significant difference between the groups. Severe autograft valve insufficiency at the time of redo (OR 4.07, P = 0.03) and patient age (OR 1.07, P = 0.04) were associated with a valve replacement procedure instead of VSP. The median follow-up duration was 34 months. No late deaths occurred in either group. Freedom from VSP failure and aortic prosthesis dysfunction were 93.8% and 94.1% in the VSP and BP groups, respectively. No reoperations were necessary in either group.ConclusionRedo aortic root surgery can be safely performed in patients with autograft failure. Both root replacement and autograft valve-sparing procedures demonstrated acceptable results at mid-term follow-up. Early redo surgery pre-empting severe aortic insufficiency increases the likelihood of preservation of the dilated autograft valve.

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]

It has been proposed that delaying the Ross procedure to later in childhood, allowing autograft stabilisation and placement of a larger pulmonary conduit, may improve outcomes. However, the effect of age at the time of Ross procedure on outcomes remains unclear. All patients who underwent the Ross procedure between 1995 and 2018 were included in the study. Patients were divided into four groups: infants, age 1 to 5 years, age 5 to 10 years and age 10 to 18 years. A total of 140 patients underwent the Ross procedure in the study period. Early mortality was 23.3% (7/30) for infants compared to 0% for older children (p <0.001). Survival at 15 years was significantly lower in infants (76.3%±9.9%), compared to children aged 1 to 5 years (90.9%±20.1%), 5 to 10 years (94%±13.3%), and 10 to 18 years (86.7%±10.0%), p =0.01. Freedom from autograft reoperation at 15 years was significantly lower in infants (58.4%±16.2%), compared to children aged 1 to 5 years (77.1%±14.9%), 5 to 10 years (84.2%±6.0%) and 10 to 18 years (87.8%±9.0%), p =0.01. Overall freedom from reoperation at 15 years was 13.0%±6.0% for infants, 24.2%±9.0% for children aged 1 to 5 years, 46.7%±15.8% for children aged 5 to 10 years, and 78.4%±10.4%, p <0.001. The Ross procedure performed after 10 years of age appears to be associated with improved freedom from reoperation, primarily due to a reduction in reoperation on the pulmonary conduit. [ABSTRACT FROM AUTHOR]

The Ross procedure allows replacement of a diseased aortic valve with pulmonary root autograft, possibly avoiding the highly thrombotic mechanical valves and immunologic deterioration of tissue valves in antiphospholipid syndrome (APS). Here, we present the use of the Ross procedure in a 42‐year‐old woman with mild intellectual disability, APS, and a complex anticoagulation history after she presented with thrombosis of her mechanical On‐X aortic valve previously implanted for non‐bacterial thrombotic endocarditis. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES After a Ross procedure, autograft failure can occur. At reoperation, repair of the autograft preserves the advantages of the Ross procedure. The aim of this retrospective study was to assess mid-term results after reoperation of a failed autograft. METHODS Between 1997 and 2022, 30 consecutive patients (83% male; age 41 ± 11 years) underwent autograft reintervention between 60 days and 24 years (median 10 years) after a Ross procedure. The initial technique varied, full-root replacement (n  = 25) being the most frequent. The indication for reoperation was isolated autograft regurgitation (n  = 7), root dilatation (>43 mm) with (n  = 17) or without (n  = 2) autograft regurgitation, mixed dysfunction (n  = 2) and endocarditis (n  = 2). In 4 instances, the valve was replaced by valve (n  = 1) or combined valve and root replacement (n  = 3). Valve-sparing procedures consisted of isolated valve repair (n  = 7) or root replacement (n  = 19), and tubular aortic replacement. Cusp repair was performed in all but 2. Mean follow-up was 5.4 ± 6 years (35 days to 24 years). RESULTS Mean cross-clamp and perfusion times were 74 ± 26 and 132 ± 64 min. There were 2 perioperative deaths (7%; both valve replacement) and 2 patients died late (32 days to 1.2 years postoperatively). Freedom from cardiac death at 10 years was 96% after valve repair and 50% after replacement. Two patients required reoperation (1.68 and 16 years) following repair. One underwent valve replacement for cusp perforation, the other, root remodelling for dilatation. Freedom from autograft reintervention at 15 years was 95%. CONCLUSIONS Autograft reoperations after the Ross procedure can be performed as valve-sparing operations in the majority of cases. With valve-sparing, long-term survival and freedom from reoperation are excellent. [ABSTRACT FROM AUTHOR]

Background Transcatheter valve replacement is a less invasive alternative to surgical valve replacement and has become increasingly popular. It is often the preferred approach for patients with high surgical risk. In patients with multiple prior sternotomies and multi-valvular failure, sequential transcatheter valve replacements may be a viable option. Case summary We present the case of a 61-year-old-man with two prior sternotomies who underwent sequential transcatheter replacements of the aortic and pulmonic valves for symptomatic aortic and pulmonary stenosis. He was deemed high risk for a repeat sternotomy. The decision to perform sequential transcatheter aortic valve replacement (TAVR) and transcatheter pulmonic valve replacement (TPVR) a month apart was made. Patient underwent valve-in-valve TAVR in a stentless bioprosthetic valve with 29-mm Edwards Sapien 3 followed by TPVR with 26-mm Edwards Sapien 3. He tolerated both procedures well and was asymptomatic at 1-month follow up. Discussion To our knowledge, this is the first reported successful case of sequential TAVR and TPVR with right ventricular outflow tract stenting in a patient with both aortic and pulmonic bioprosthetic valve dysfunction. Our case demonstrates that transcatheter approach to multi-valvular replacements may be a viable option for high-risk surgical patients. [ABSTRACT FROM AUTHOR]

The presence of severe right ventricular outflow tract calcification may preclude safe and effective transcatheter pulmonary valve replacement in patients with pulmonary allograft stenosis owing to the risk of conduit tear and suboptimal annular expansion. Debulking calcium using intravascular lithotripsy within the right ventricular outflow tract may mitigate this risk and improve valve hemodynamics. (Level of Difficulty: Advanced.)

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, where a pulmonary autograft (neoaorta) replaces the aortic valve, has excellent long-term outcomes in patients with congenital aortic valve disease. However, there are reports of neoaortic dilatation and dissection. An increasing number of women are wishing to become pregnant following the Ross procedure, but little is known about the occurrence and risks of neoaortic dilatation and complications in pregnancy. We investigated neoaorta function and outcomes in pregnancy following the Ross procedure. This retrospective study investigated women post-Ross procedure at a tertiary ACHD unit between 1997 and 2021. Imaging evaluated neoaortic root dimensions and regurgitation pre-, and post- pregnancy, compared with matched non-pregnant controls. Primary endpoints were change in neoaortic dimensions, degree of regurgitation and adverse maternal outcomes. Nineteen pregnancies in 12 women were included. The mean change in neoaortic root diameter post-pregnancy was 1.8 mm (SD 3.4) (p = 0.017). There was no significant change in neoaortic dimensions in matched controls during follow-up. There were no cases of dissection, arrhythmia, acute coronary syndrome, or maternal mortality. Three deliveries were pre-term, including one emergency Caesarean section due to maternal cardiac decompensation, requiring aortic root replacement post-partum but there were no neonatal deaths. Pregnancy following the Ross procedure is associated with neoaortic dilatation, and pregnancy is generally well tolerated. Although adverse maternal outcomes are uncommon, there are still rare cases of cardiac complications in and around the time of pregnancy. These findings emphasise the need for accessible pre-pregnancy counselling, risk stratification and careful surveillance through pregnancy by specialist cardio-obstetric multi-disciplinary teams. • The Ross procedure has excellent outcomes in congenital aortic valve disease. • Neoaortic dilatation occurs in pregnancy, yet adverse maternal outcomes are rare. • Pre-pregnancy counselling and surveillance by the multidisciplinary team is key. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Contemporarily modified Ross procedure continues to deliver excellent outcomes and remains part of the treatment strategy for aortic valve disease in the young adult population. The aim of this study was to assess whether Ross procedure carried out as a second or subsequent intervention for aortic valve disease carries similar risk and long-term benefit, when compared to Ross procedure for the first-time aortic valve replacement. METHODS A total of 158 patients aged 16–60 years from a single congenital cardiac centre between 1997 and 2020 were included. The sample was split into 2 subgroups, based on the history of previous aortic valve interventions prior to the Ross procedure. Primary outcomes were defined as survival and pulmonary autograft failure. Coarsened exact matching was used to balance for covariates. RESULTS A total of 103 patients underwent primary Ross and 55 underwent secondary Ross with a mean follow-up of 7.8 years. Twenty-two patients underwent 28 reoperations during follow-up. Forty-nine well-matched pairs were obtained through matching. Freedom from pulmonary autograft failure at 10 years was 84.5% in the primary group vs 100% in the secondary group (P  = 0.021). Five- and ten-year survival were identical, 97.5% in the primary group vs 95.6% in the secondary group (P  = 0.53). Male sex and era were found to be predictors of neoaortic root dilatation. CONCLUSIONS The lower incidence of graft failure seen in secondary Ross could justify a stepwise approach to aortic valve intervention. Ross procedure delivers excellent outcomes in the adult population with no difference in survival for primary or secondary Ross. [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]

Objectives: To evaluate our 12-year experience with the Ross procedure in adults. Methods: A retrospective analysis of 215 cases of the Ross procedure was performed. The mean age of the patients was 36 ± 11.1 years, and the male to female ratio was 75% to 25%, respectively. The pulmonary autograft was placed into the aortic position using the full-root replacement technique and its modified versions. The right ventricular outflow tract was reconstructed using a pulmonary homograft in all cases. Results: The 30-day mortality after the operation was 0.9% (2 patients). The median duration of follow-up was 6.1 years (interquartile range, 6.5 years) and was complete in 86% of cases. The survival at 12 years was 94.7% and was comparable with the survival rate of the general population matched for age and sex. At the end of the follow-up, freedom from reoperation due to pulmonary autograft and homograft dysfunction was 89.1% and 99%, respectively. Conclusions: In our series, the Ross procedure resulted in low early mortality and excellent survival in adults. The long-term survival was not statistically different from the survival of the general population. The pulmonary homograft offered an excellent durability and freedom from reoperation.

The ideal substitute in young and middle-aged adults requiring aortic valve replacement (AVR) remains a matter of debate and poses a challenge for the heart team. In patients with good-quality cusps and aortic root dilatation, valve-sparing root replacement (VSRR)- David procedure / Florida sleeve modification, has become a standard for preserving native aortic valve when aortic root replacement is needed. In young patients with aortic valve disease the Ross procedure offers a potential alternative to the prosthetic AVR. We retrospectively identified all patients with aortic root dilatation, aortic insufficiency, aortic stenosis or mixed aortic valve disease who underwent David procedure, Florida sleeve modification, isolated aortic valve repair and the Ross procedure at our department between September 2022 and October 2024. From 59 consecutive patients, 34 patients (57%) underwent David procedure, 4 patients (6%) Florida sleeve modification, 11 patients (18%) isolated aortic valve repair and 10 patients (16%) underwent the Ross procedure. There were no in hospital mortality. In young patients with aortic valve disease, complications from prosthetic valves necessitate a better approach. In addition to alleviating the need for anticoagulation, the VSRR procedure and the Ross procedure offer a hemodynamic profile similar to the native aortic valve and carry a low risk of endocarditis. Contemporary advancements and experience acquired in complex aortic root surgery highlighted the importance of reinforcing the annulus and sinotubular junction of the pulmonary autograft. Thus, the Ross procedure was revived as an intriguing alternative to prosthetic AVR. Furthermore, recent data shows that the Ross procedure is the only AVR procedure that restores the life expectancy of the general population. [ABSTRACT FROM AUTHOR]

Background The Ross operation appears to restore normal survival in young and middle‐aged adults with aortic valve disease. However, there are limited data comparing it with conventional aortic valve replacement. Herein, we compared outcomes of the Ross procedure with mechanical and bioprosthetic aortic valve replacement (M‐AVR and B‐AVR, respectively). Methods and Results MEDLINE and EMBASE were searched through March 2022 to identify randomized controlled trials and propensity score–matched studies that investigated outcomes of patients aged ≥16 years undergoing the Ross procedure, M‐AVR, or B‐AVR. The systematic literature search identified 2 randomized controlled trials and 8 propensity score–matched studies involving a total of 4812 patients (Ross: n=1991; M‐AVR: n=2019; and B‐AVR: n=802). All‐cause mortality was significantly lower in the Ross procedure group compared with M‐AVR (hazard ratio [HR] [95% CI], 0.58 [0.35–0.97]; P=0.035) and B‐AVR (HR [95% CI], 0.32 [0.18–0.59]; P

Relevant pressure recovery (PR) has been shown to increase functional stenotic aortic valve orifice area and reduce left ventricular load. However, little is known about the relevance of PR in the pulmonary artery. The study examined the impact of PR using 2D‐echocardiography in the pulmonary artery distal to the degenerated homograft in patients after Ross surgery. Ninety‐two patients with pulmonary homograft were investigated by Doppler echocardiography (mean time interval after surgery 31 ± 26 months). PR was measured as a function of pulmonary artery diameter determined by computed tomography angiography. Homograft orifice area, valve resistance, and transvalvular stroke work were calculated with and without considering PR. PR decreased as the pulmonary artery diameter increased (r = −0.69, p < 0.001). Mean PR was 41.5 ± 7.1% of the Doppler‐derived pressure gradient (Pmax), which resulted in a markedly increased homograft orifice area (energy loss coefficient index [ELCOI] vs. effective orifice area index [EOAI], 1.3 ± 0.4 cm2/m2 vs. 0.9 ± 0.4 cm2/m2, p < 0.001). PR significantly reduced homograft resistance and transvalvular stroke work (822 ± 433 vs. 349 ± 220 mmHg × ml, p < 0.0001). When PR was considered, the correlations of the parameters used were significantly better, and 11 of 18 patients (61%) in the group with severe homograft stenosis (EOAI <0.6 cm2/m2) could be reclassified as moderate stenosis. Our results showed that the Doppler measurements overestimated the degree of homograft stenosis and thus the right ventricular load, when PR was neglected in the pulmonary artery. Therefore, Doppler measurements that ignore PR can misclassify homograft stenosis and may lead to premature surgery. [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 interventions remain the most effective treatment for severe aortic stenosis. In the recent years, advances in bioprosthetics and newer data have reduced the cut-off age for the use of bioprosthetic valves in younger patients, but the debate on whether to favor mechanical valves in younger patients remains a constant, especially with the undesired effects and considerations of anticoagulation therapy with vitamin K antagonists in this age group. Other options like the Ross procedure are gaining traction, despite still being undervalued and necessitating expertise centers. Hemodynamic considerations and durability of these options are important to consider, especially in this age group. Regardless of the choice of the prosthesis, patient informed consent is paramount since the decision affects the lifetime management of their initial condition, and expectations given must remain realistic. [ABSTRACT FROM AUTHOR]

Although mid- and long-term outcomes after the Ross procedure for aortic valve disease have been increasingly improving over the years, this is still a rather challenging operation in neonates and small children. This is particularly true for patients with associated congenital heart defects and critical clinical conditions. Herein we describe the application of this procedure as a rescue operation in emergency circumstances in a low-birth-weight neonate with severe aortic stenosis, aortic regurgitation and mitral regurgitation after a previous aortic coartectomy. [ABSTRACT FROM AUTHOR]

Objectives: The Ross procedure is currently receiving renewed interest. Its function and durability depend on preservation of pulmonary valve anatomy; limited data exists on normal pulmonary valve geometry. The objective was to compare aortic and pulmonary root and cusp dimensions in adults with normal tricuspid aortic and pulmonary valves., Methods: We reviewed 507 coronary computed tomography studies, selecting those with adequate visibility of both pulmonary and aortic roots for further analysis. Diastolic aortic and pulmonary root and cusp dimensions were measured. Root dimensions at different phases of the cardiac cycle were measured in three patients., Results: We analysed studies of 50 patients with the mean age of 54 years (SD : 16). In end-diastole, pulmonary root had a smaller sinutubular to basal ring ratio than the aortic root (0.82 (SD : 0.09) vs 1.14 (SD : 0.12), P < 0.001). Aortic and pulmonary cusps had similar dimensions; however, pulmonary cusp effective height was lower (5.9 mm (SD : 1.6) vs 8.4 mm (SD : 1.2), P < 0.001). Pulmonary basal ring perimeter was largest at end-diastole and smallest at end-systole, with the relative difference of 23.5% (SD : 2.7)., Conclusions: The pulmonary root has a similar cusp size compared to the aortic root, but a different shape, resulting in a lower pulmonary cusp effective height. The perimeter of the pulmonary basal ring changes during the cardiac cycle. These findings suggest that stabilising the autograft to normal aortic, rather than pulmonary, root dimensions should result in normal autograft cusp configuration. CTA could become a tool for personalized planning of the Ross procedure., Meeting Presentation: Presented at the 38th EACTS meeting in October 2024 in Lisbon., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objective: Preoperative aortic insufficiency (AI) is associated with inferior autograft durability after the Ross procedure. However, many patients with aortic stenosis (AS) undergo balloon aortic valvuloplasty (BAV) early and present with longstanding AI before Ross. We studied how BAV and subsequent valvular pathology impacts autograft durability., Methods: Patients undergoing the Ross operation from 1993 to 2020 were identified. Those who underwent BAV before Ross were compared with patients who did not undergo BAV and underwent Ross for predominant AI (AI group) or AS (AS group). Those who underwent previous open surgical aortic valve intervention were excluded. Primary outcome of interest was autograft failure, defined as a composite of autograft reintervention or severe insufficiency., Results: A total of 198 patients were included. Seventy-nine (39.9%) underwent BAV and subsequently underwent the Ross for predominant AI (45.6%) or AS (54.4%). Of patients who did not undergo BAV, 66 (33.3%) presented with predominant AI and 53 (26.8%) with AS. Freedom from autograft failure at 15 years was 90%, 92%, and 62% in BAV, AS, and AI groups, respectively. The AI group was at significantly increased risk of long-term autograft failure (hazard ratio, 5.6; P = .01), whereas the AS and BAV groups had similar, low risk (hazard ratio, 1.1; P = .91). Autograft durability was similar among patients who received BAV and presented with AS or AI before the Ross (P = .84)., Conclusions: BAV before the Ross procedure is common in patients with AS. These patients have excellent long-term autograft durability regardless of preoperative valvular pathology and should strongly be considered for the Ross operation., Competing Interests: Conflict of Interest Statement Dr Takayama reported speaker with Terumo, consultant with Artivion and Edwards, and research grant from the Rudin Foundation. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Right ventricular (RV) conduit availability and degeneration are potential limitations of the Ross procedure. Pulmonary homografts are the gold standard, but their limited availability drives the need for alternatives. The aim of this study was to compare results of different RV conduits., Methods: Between 1995 and 2023, 315 consecutive patients (73% males; mean age, 37 ± 12 years) underwent a Ross procedure using a homograft (n = 211), bovine jugular vein (BJV) (n = 34), or xenograft (n = 70) as the RV conduit. The mean follow-up was 5.7 ± 6.7 years and was 96% complete (1631 patient-years)., Results: Twelve patients (homograft, n = 8; BJV. n = 3; xenograft, n = 1) required RV conduit reintervention, including 4 patients within 4 years (all with homografts). Indications for reintervention were degeneration in 8 patients and active endocarditis in 4 patients. Reinterventions included RV conduit replacement (homograft, n = 3; xenograft, n = 1; BJV, n = 2) and transcatheter valve implantation (homograft n = 5; BJV, n = 1). At 15 years, freedom from RV conduit reintervention was 88%, and freedom from reoperation was 93%. Freedom from reintervention at 15 years was similar in the homograft (89%), BJV (89%), and xenograft (100%) groups (P = .812). Progression of mean RV conduit gradient was lowest for the BJV group (1.45 mm Hg/year) and similar in the homograft (2.6 mm Hg/year) and xenograft (2.9 mm Hg/year) groups. Age at <18 years at surgery (hazard ratio [HR], 1.9; P < .001) was a predictive risk factor for reintervention. There was no difference among the RV conduit groups (HR, 1.198; P = .606)., Conclusions: The incidence of reintervention after 15 years is similar in recipients of homografts, xenografts, and BJV grafts. Interestingly, homografts may fail in the first few years, possibly related to inflammatory phenomena. Thus, the use of xenografts may be an option if homografts are not available., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the influence of initial intervention on the long-term outcomes in congenital aortic stenosis., Methods: Two hundred forty-three children underwent initial intervention between 1997 and 2022, by surgical valvuloplasty in 92 (32% neonates, 36% infants) and balloon valvuloplasty in 151 (27% neonates, 30% infants). Twenty-eight patients (11.5%) had associated mitral valve stenosis. Competing risk analysis for death, alive after initial intervention, or alive after aortic valve replacement (AVR) was performed and factors influencing survival or AVR examined., Results: There were 9 early deaths (3.7%). During a median follow-up of 13.5 years (range, 1.5-26.7), 98 patients had reintervention on the aortic valve (40.3%), whereas 145 had AVR (59.6%) at a median age of 14.0 years (interquartile range, 9.0-17.0), which was by Ross procedure in 130 (89.6%). Of the 12 late deaths, 3 were perioperative and 9 occurred as outpatients. There were no perioperative or late deaths after AVR. AVR occurred earlier in patients who had initial balloon (12.0 years [interquartile range, 5.0-14.5]) rather than surgical (18.5 years [interquartile range, 15.5-21.5]) valvuloplasty (P < .05). Actuarial survival in the cohort was 91.3% at 25 years, with no difference between the 2 initial interventions. Critical aortic stenosis, mitral stenosis, and initial intervention as a neonate were independent risk factors for worse survival., Conclusions: We demonstrate excellent early and late survival in patients with congenital aortic stenosis after initial balloon or surgical valvuloplasty. Whilst children who had balloon valvuloplasty had AVR earlier than those who had initial surgical valvuloplasty, patient factors had a greater influence on survival than choice of initial intervention., Competing Interests: Conflicts of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Abstract Relevant pressure recovery (PR) has been shown to increase functional stenotic aortic valve orifice area and reduce left ventricular load. However, little is known about the relevance of PR in the pulmonary artery. The study examined the impact of PR using 2D‐echocardiography in the pulmonary artery distal to the degenerated homograft in patients after Ross surgery. Ninety‐two patients with pulmonary homograft were investigated by Doppler echocardiography (mean time interval after surgery 31 ± 26 months). PR was measured as a function of pulmonary artery diameter determined by computed tomography angiography. Homograft orifice area, valve resistance, and transvalvular stroke work were calculated with and without considering PR. PR decreased as the pulmonary artery diameter increased (r = −0.69, p

An inherent limitation of the Ross procedure is long-term two valve disease which will require repetitive reintervention. In this case, a 31-year-old man who had underwent Ross operation due to congenital bicuspid valve 20 years before, underwent double root replacement: valve sparing root reimplantation concomitant with the right ventricular outflow tract (RVOT) reconstruction with a bioprosthesis for severe RVOT stenosis. Although the diameter of autograft root was 42 mm and aortic insufficiency was mild, we added root surgery due to concerns regarding autograft root dilation in response to left ventricular volume load after RVOT reconstruction. The postoperative echocardiogram showed minimal aortic valve regurgitation and normal blood flow in the RVOT, and he was discharged from the hospital on the 17th day after the surgery. In this report, we present the outcomes of Valve-sparing double root replacement following Ross surgery. [ABSTRACT FROM AUTHOR]

Purpose of Review: Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality. It has a wide spectrum of clinical manifestations including aortic regurgitation (AR), aortic stenosis, and an associated aortopathy with a small but increased risk of aortic dissection. This review describes current knowledge of BAV, from anatomy and genetics to a discussion of multifaceted strategies utilized in the management of this unique patient population. This review will also highlight critical knowledge gaps in areas of basic and clinical research to enhance further understanding of this clinical entity. Recent Findings: The current knowledge regarding pathophysiologic mechanisms, screening, and surveillance guidelines for BAV and the associated aortopathy is discussed. We also discuss current management techniques for aortic valve repair versus replacement, indications for aortic surgery (root or ascending aorta), and the emergence of the Ross procedure as a viable management option not only in children, but also in adolescents and adults. Summary: The varied clinical phenotype of the BAV, resulting in its specific complex hemodynamic interactions, renders it an entity which is separate and distinct from the tricuspid aortic valve pathologies. While various aortic histopathologic and protein alterations in BAV patients have been described, it remains unclear if these changes are causal or the result of hemodynamic alterations imposed by sheer stress on the intrinsically dysfunctional BAV. Medical management for patients with BAV with AS, AI, or dilated aortic roots/ascending aortas remains challenging and needs further investigation. More than 50% of patients with BAV will undergo AVR during their lifetime, and more than 25% of patients with BAV undergo aortic surgery performed for dilation of the aortic root or ascending aorta, often concurrently with AVR. The search for the ultimate genetic or epigenetic cause of the different bicuspid phenotypes will ultimately be facilitated by the next-generation sequencing tools that allow for study of large populations at low cost. Improvements in diagnostic and stratification criteria to accurately risk assess BAV patients are critical to this process. [ABSTRACT FROM AUTHOR]

Background: The major limitation to the Ross operation is a progressive autograft dilation, possibly leading to reoperations. A murine model was created to evaluate pulmonary artery graft (PAG) adaptation to pressure overload. Methods: Lewis rats (n = 17) underwent heterotopic surgical implantation of a PAG, harvested from syngeneic animals (n = 17). A group of sham animals (n = 7) was used as a control. Seriated ultrasound studies of the PAG were performed. Animals were sacrificed at 1 week (n = 5) or 2 months (n = 15) and the PAG underwent mechanical and histopathological analyses. Results: Echography showed an initial increase in diameter (p < 0.001) and a decrease in peak systolic velocity (PSV). Subsequently, despite no change in diameter, an increase in PSV was observed (p < 0.01). After 1 week, the stiffness of the PAG and the aorta were similar, while at 2 months, the PAG appeared more rigid (p < 0.05). PAG's histological analysis at 2 months revealed intimal hyperplasia development. The tunica media showed focal thinning of the elastic lamellae and normally distributed smooth muscle cells. Conclusions: We demonstrated a stiffening of the PAG wall after its implantation in systemic position; the development of intimal hyperplasia and the thinning of the elastic lamellae could be the possible underlying mechanism. [ABSTRACT FROM AUTHOR]