The Ross procedure performed for aortic insufficiency is associated with increased autograft reoperation

The Ross procedure in infants/children is generally accepted, while in adults it remains controversial. We examined our adult experience for clinical and operative factors that predict autograft reoperation.

Prospectively collected data of 160 consecutive adults undergoing a Ross procedure by a single surgeon from July 1994 through June 2008 were reviewed. Clinical follow-up was obtained in 160 of 160 (100%) and echocardiogram in 150 of 152 (98.7%) survivors. Multivariate proportional hazards analysis was employed to determine risk factors for autograft reoperation.

Mean age was 42.0±11.1 years and 73.1% were male. Presenting pathology was aortic insufficiency (AI) in 93 (58.1%) and aortic stenosis (AS) in 67 (41.9%). Bicuspid aortic valves accounted for 91% of AS and 85% of AI patients. Annuloplasty was required in 49 of 93 (52.7%) patients with AI and 12 of 67 (17.9%) patients with AS (p<0.001). There were 3 operative mortalities (1.87%) with 2 late cardiac related deaths (1.3%). Kaplan-Meier survival was 92.9±0.03% at 7.5 years. Fifteen patients (9.4%) required reoperation on the autograft root; 14 of 15 (93.3%) had AI. The time to aortic valve reoperation significantly diverged at 7.5 years; patients with AI required more reoperations. Factors predicting increased risk of autograft reoperation included female gender (hazard ratio [HR]=7.7; 95% confidence interval [CI] 1.3 to 46.6), aortic dilatation (HR=6.3; 95% CI 1.3 to 33.2), a 3-cusp valve (HR=8.1; 95% CI 1.3 to 53.3) and annuloplasty (HR=7.8; 95% CI 1.2 to 52.0).

The Ross procedure in adults provides excellent freedom from autograft failure in patients operated for AS. Other treatment alternatives should be strongly considered in adults presenting primarily with aortic insufficiency.