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Risk factors, dynamics, and cutoff values for homograft stenosis after the Ross procedure
Horea Feier1, Frederic Collart, Olivier Ghez
1Department of Adult and Pediatric Cardiac Surgery, La Timone University Hospital, Marseille, France.
Insights
Homograft size and a transhomograft gradient over 9 mm Hg at one year predict stenosis after the Ross procedure. Most stenosis progression occurs within 24 months, highlighting early monitoring importance.
Area of Science:
- Cardiovascular Surgery
- Biomaterials Science
- Medical Imaging
Background:
- The Ross procedure uses homografts, which can develop stenosis.
- Identifying factors predicting homograft stenosis is crucial for patient outcomes.
Purpose of the Study:
- Determine homograft-related factors predicting stenosis post-Ross procedure.
- Analyze the natural progression of homograft stenosis.
- Establish echographic predictors for stenosis at one year.
Main Methods:
- Prospective follow-up of 71 patients undergoing the Ross procedure.
- Transthoracic echocardiography for stenosis assessment (mean gradient ≥ 20 mm Hg).
- Univariate, multivariate, and survival analyses to identify risk factors.
Main Results:
- Homograft size and a transhomograft gradient > 9 mm Hg at 1 year predicted stenosis.
- Stenosis-free survival rates decreased over time (85.9% at 1 year, 68.6% at 5 years).
- A 1-year gradient cutoff of 9 mm Hg predicted future stenosis.
Conclusions:
- Homograft size is a key factor in stenosis development.
- Significant transhomograft gradient increase occurs within the first 24 months.
- A gradient ≥ 9 mm Hg at 1 year post-procedure indicates a high risk for late stenosis.
Background:
The purpose of this study was to find homograft-related factors that might be associated with the development of stenosis after the Ross procedure, as well as to identify the natural dynamics of stenosis and find echographic cutoff values after one year of follow-up that might predict such an outcome.
Methods:
We followed up 71 patients (mean age, 24.27 +/- 16.57 years) who had such a procedure prospectively by transthoracic echocardiography, between 1993 and 2002. Follow-up was 55.26 +/- 29.63 months and was 90.14% complete. Homografts were harvested from heart-beating donors or cardiac transplant recipients. Allograft stenosis was analyzed and risk factors were identified by univariate, multivariate, and survival analysis methods. Stenosis was defined as a mean gradient greater than or equal to 20 mm Hg.
Results:
There were two reoperations and 21 homografts were stenotic at the last follow-up, ten of which were already so at one year after the procedure. Cox regression analysis revealed a transhomograft gradient greater than 9 mm Hg at 1 year after the procedure (hazard ratio [HR] = 10.04) and homograft size (HR = 0.75) as independent predictors for stenosis. Stenosis-free survival was 85.94 +/- 4.35%, 75.51 +/- 5.55%, and 68.56 +/- 6.34 after 1, 3, and 5 years, respectively. A cutoff value of 9 mm Hg at 1 year of follow-up could predict different stenosis-free survival rates.
Conclusions:
Homograft size is the most important homograft-related factor for stenosis. Most of the increase in transhomograft gradient occurs in the first 24 months. A gradient of 9 mm Hg or more after 1 year predicts the late occurrence of stenosis.
