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Long-term outcomes following the Ross procedure in neonates and infants: A multi-institutional analysis
Jason W Greenberg1, Madison Argo2, Awais Ashfaq1
1Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Insights
The Ross procedure offers excellent long-term survival and freedom from reintervention for neonates and infants with aortic valve disease. Neoaortic dilatation after the Ross procedure normalizes over time, supporting its consideration in this population.
Area of Science:
- Pediatric Cardiac Surgery
- Aortic Valve Repair
- Congenital Heart Disease
Background:
- The Ross procedure has historically shown high morbidity and mortality in neonates and infants with aortic valve pathology.
- Long-term durability data for the Ross procedure in this young population are limited.
Purpose of the Study:
- To evaluate the long-term outcomes of the Ross procedure in neonates and infants.
- To assess neoaortic size and function evolution after the Ross procedure in this cohort.
Main Methods:
- Retrospective analysis of 133 infants undergoing the Ross procedure between 1996 and 2016 at 6 tertiary care centers.
- Minimum 5-year follow-up with serial echocardiograms to track neoaortic size and function.
Main Results:
- In-hospital mortality was 10% (13/133), with 8% postdischarge mortality.
- Neoaortic dilatation peaked at 2-3 years post-procedure before normalizing.
- Freedom from moderate/severe neoaortic regurgitation was 86% at 15 years, with 4% requiring reintervention.
Conclusions:
- The Ross procedure demonstrates excellent postdischarge survival and long-term freedom from reintervention and aortic regurgitation in neonates and infants.
- Neoaortic dilatation is a transient phenomenon that normalizes over the long term.
- The Ross procedure warrants increased consideration for neonates and infants with aortic valve disease.
Objectives:
For neonates and infants with aortic valve pathology, the Ross procedure historically has been associated with high rates of morbidity and mortality. Data regarding long-term durability are lacking.
Methods:
The international, multi-institutional Ross Collaborative included 6 tertiary care centers. Infants who underwent a Ross operation between 1996 and 2016 (allowing a minimum 5 years of follow-up) were retrospectively identified. Serial echocardiograms were examined to study evolution in neoaortic size and function.
Results:
Primary diagnoses for the 133 patients (n = 30 neonates) included isolated aortic stenosis (14%, n = 19), Shone complex (14%, n = 19), and aortic stenosis plus other (excluding Shone complex; n = 95, 71%), including arch obstruction (n = 55), left ventricular hypoplasia (n = 9), and mitral disease (moderate or greater stenosis or regurgitation, n = 31). At the time of the Ross procedure, median age was 96 days (interquartile range, 36-186), and median weight was 4.4 kg (3.6-6.5). In-hospital mortality occurred in 13 of 133 patients (10%) (4/30 [13%] neonates). Postdischarge mortality occurred in 10 of 120 patients (8%) at a median of 298 days post-Ross. Post-Ross neoaortic dilatation occurred, peaking at 4 to 5 SDs above normal at 2 to 3 years before returning to near-baseline z-score at a median follow-up of 11.5 [6.4-17.4] years. Autograft/left ventricular outflow tract reintervention was required in 5 of 120 patients (4%) at a median of 10.3 [4.1-12.8] years. Freedom from moderate or greater neoaortic regurgitation was 86% at 15 years.
Conclusions:
Neonates and infants experience excellent postdischarge survival and long-term freedom from autograft reintervention and aortic regurgitation after the Ross. Neoaortic dilatation normalizes in this population in the long-term. Increased consideration should be given to Ross in neonates and infants with aortic valve disease.
