Reoperations after the ross procedure in adults: towards autograft-sparing/Ross reversal

The risk of reoperation and loss of a second native valve is a major drawback of the Ross operation. The study aim was to examine the indications, pathologies, procedures, and outcomes for reoperation after the Ross procedure, emphasizing the potential for autograft salvage.

Between 1994 and 2009, a total of 60 reoperations was performed on 55 patients who previously had undergone the Ross procedure. Attention was focused on 49 patients with first-time reoperation for autograft or allograft-related problems (37 males, 12 females; mean age 49 +/- 14 years). At the original operation, 23% of patients had a history of endocarditis, 14% a previous valve replacement, and 61% a bicuspid aortic valve. The original implant technique was full root in 88% of cases, inclusion root in 2%, or subcoronary implant in 9%. Autograft and aortic indications (n = 38) included root and ascending aorta dilatation (53%), structural valve cusp deterioration (32%), endocarditis (11%), and technical failure (5%). Regurgitation was moderate to severe in 97% of cases. Pulmonary indications (n = 21) were allograft degeneration (71%), endocarditis (10%), and Ross reversal (19%). The autograft and aorta reoperation procedures (n = 38) included ascending aorta replacement (n = 2), David reimplantation (n = 1), valve repair (n = 2), valve replacement (n = 13), and root replacement (n = 22). Pulmonary valve replacements (n = 21) were with pulmonary allograft in 12 cases and autograft (Ross reversal) in nine. Twelve of the pulmonary valve replacement group, including the Ross reversals, were combined aortic and pulmonary. During the last 13 reoperations, only two autografts were lost, both of which were potentially salvageable.

No intraoperative adverse events or postoperative deaths occurred, and minimal morbidity was observed. During the follow up period there was one death, while two patients required reoperation (one for endocarditis and one non-valve-related).

Reoperation at up to 12 years after a Ross procedure was most commonly required for autograft failure, and less often for allograft degeneration. Of reassurance to prospective Ross patient was the finding that reoperation can be performed safely, and that the autograft can be salvaged either by repair and valve-sparing reimplantation in the aortic position, or by Ross reversal.