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The Ross procedure in children and young adults: a word of caution
A Laudito1, M M Brook, S Suleman
1Departments of Pediatric Cardiac Surgery, University of California, San Francisco, CA, USA.
Insights
The Ross procedure is a viable aortic valve replacement for children, but caution is advised for patients with pre-existing aortic insufficiency, as this increases the risk of autograft failure. Further research is needed to refine indications.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Thoracic Surgery
Background:
- Aortic valve disease management in pediatric patients presents challenges.
- The Ross and Ross-Konno procedures offer advantages like growth potential and no need for anticoagulation.
- Concerns exist regarding the long-term durability of the pulmonary autograft, particularly with aortic insufficiency.
Purpose of the Study:
- To evaluate the outcomes of the Ross and Ross-Konno procedures in children and young adults.
- To identify risk factors associated with autograft dysfunction after these procedures.
Main Methods:
- A retrospective review of 72 Ross and Ross-Konno procedures performed between June 1993 and February 2000.
- Analysis of clinical, echocardiographic, and hemodynamic data from preoperative, postoperative, and follow-up periods.
- Statistical analysis to determine risk factors for autograft failure.
Main Results:
- Aortic insufficiency was a significant preoperative indication for the Ross procedure in 27 patients.
- No deaths occurred during follow-up (5-80 months).
- Seven patients required reoperation for severe aortic insufficiency; five others had moderate insufficiency. Preoperative aortic insufficiency was a statistically significant risk factor for autograft failure (P=.031).
Conclusions:
- The Ross and Ross-Konno procedures have improved outcomes for pediatric aortic valve disease.
- Caution is recommended when performing the Ross procedure in older children with preoperative aortic insufficiency.
- Further studies are needed to refine indications and understand autograft dysfunction risk factors in this population.
Background:
Disease of the aortic valve in children and young adults is a complex entity whose management is the subject of controversy. The Ross and the Ross-Konno procedures have become the primary choices for aortic valve replacement in children because of growth potential, optimal hemodynamic performance, and lack of the need for anticoagulation. However, concern persists regarding the longevity of the pulmonary autograft, especially in patients with aortic insufficiency.
Methods:
Between June 1993 and February 2000, 72 Ross and Ross-Konno procedures were performed at our institution: 81% of the patients were less than 15 years old. Preoperative, postoperative, and follow-up clinical, echocardiographic, and hemodynamic data were reviewed. Statistical analysis was performed to identify the risk factors for deteriorating autograft function.
Results:
Aortic insufficiency was an indication for the Ross procedure in 17 patients and mixed lesions with predominant aortic insufficiency in 10. Of the 45 other patients, 32 had aortic stenosis and 13 had mixed lesions with predominant aortic stenosis. There were no deaths during a follow-up of 5 to 80 months. Autograft reoperation was necessary in the follow-up period in 7 patients for severe aortic insufficiency. Moderate insufficiency was identified in 5 additional patients. Aortic insufficiency or predominant aortic insufficiency, as a preoperative hemodynamic indication for the Ross procedure, reached statistical significance (P =.031) as a risk factor for autograft failure.
Conclusion:
The Ross and the Ross-Konno procedures have changed the prognosis of children and young adults with complex aortic valve disease. However, the Ross procedure should be performed with caution in older children in whom aortic insufficiency is a preoperative hemodynamic indication. Further follow-up to delineate the risk factors for autograft dysfunction in children and young adults is necessary to better define the indications for the Ross procedure.