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Ross Procedure in Neonates and Infants: A European Multicenter Experience
Aart Mookhoek1, Efstratios I Charitos2, Mark G Hazekamp3
1Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.
Insights
The Ross procedure using a pulmonary autograft for aortic valve replacement in infants is high-risk but offers a durable neoaortic valve with good midterm function. Late mortality due to heart failure was an unexpected finding.
Area of Science:
- Pediatric Cardiac Surgery
- Cardiovascular Research
- Congenital Heart Defects
Background:
- Severe left ventricular outflow tract obstruction in neonates and infants often necessitates aortic root replacement.
- The Ross procedure, utilizing a pulmonary autograft, is a complex surgical option for these young patients.
- This study evaluates the midterm outcomes of the Ross procedure in this specific pediatric population.
Purpose of the Study:
- To assess the midterm survival rates following the Ross procedure in neonates and infants.
- To evaluate the durability and function of the pulmonary autograft used as a neoaortic valve.
- To identify factors associated with early and late mortality and reintervention.
Main Methods:
- A retrospective multicenter cohort study involving 76 infants (under 1 year) operated on between 1990 and 2013.
- Data collected from six congenital cardiac centers in The Netherlands and Germany.
- Analysis focused on early mortality, midterm survival, autograft function, and reintervention rates.
Main Results:
- Early mortality was 17%, associated with neonatal age, inotropic support, and aortic arch defects.
- Midterm survival showed 9% late mortality.
- Freedom from autograft reintervention was 98% at 10 years, with good valve function in 73% of patients.
- Freedom from right ventricular outflow tract reintervention was 51% at 10 years.
Conclusions:
- The Ross procedure in neonates and infants is a high-risk operation but provides a durable neoaortic valve with successful adaptation to systemic circulation.
- Midterm results demonstrate good autograft function and durability.
- Late mortality due to heart failure emerged as an unexpected outcome requiring further investigation.
Background:
Infants and neonates with severe left ventricular outflow tract obstruction may require pulmonary autograft replacement of the aortic root. In this retrospective multicenter cohort study, we present our experience with the Ross procedure in neonates and infants with a focus on midterm survival and pulmonary autograft durability.
Methods:
A retrospective observational study was performed in 76 infants (aged less than 1 year) operated on in six congenital cardiac centers in The Netherlands and Germany between 1990 and 2013.
Results:
Patients had a pulmonary autograft replacement of the aortic valve with (68%) or without (32%) septal myectomy. Median patient age was 85 days (range, 6 to 347). Early mortality (n = 13, 17%) was associated with neonatal age, preoperative use of intravenous inotropic drugs, and congenital aortic arch defects. Five patients (9%) died during follow-up. Freedom from autograft reintervention was 98% at 10 years. Echocardiography demonstrated good valve function, with no or trace regurgitation in 73% of patients. Freedom from right ventricular outflow tract reintervention was 51% at 10 years. Univariable analysis demonstrated superior freedom from reintervention of pulmonary homografts compared with aortic homografts or xenografts.
Conclusions:
Pulmonary autograft replacement of the aortic valve in neonates and infants is a high-risk operation but offers a durable neoaortic valve. Midterm durability reflects successful adaptation of the autograft to the systemic circulation. Late mortality associated with heart failure was an unexpected finding.
