Related Experiment Video
Updated: May 20, 2025
A Rodent Model of The Ross Operation: Syngeneic Pulmonary Artery Graft Implantation in A Systemic Position
Published on: April 1, 2022
Optimized outcome of the Ross procedure in children: single-centre experience†
Peter Murin1, Julia Gaal1, Robin Stenzel1
1Department of Congenital Heart Surgery-Pediatric Heart Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany.
Insights
Autograft reinforcement in the Ross procedure improved survival in children, with no significant difference in autograft reintervention rates. Homografts also showed better outcomes than xenografts for RV-PA reintervention.
Area of Science:
- Pediatric cardiac surgery
- Aortic valve repair
- Autograft reconstruction
Background:
- The Ross procedure uses a patient's own pulmonary valve (autograft) to replace a diseased aortic valve.
- Autograft failure can occur, especially during somatic growth in children.
- Autograft reinforcement strategies aim to improve durability, but data in pediatric populations are limited.
Purpose of the Study:
- To evaluate long-term survival and reintervention rates after the Ross procedure in children.
- To assess the impact of autograft reinforcement on outcomes in pediatric patients.
- To identify factors influencing reintervention risk.
Main Methods:
- A retrospective analysis of 233 pediatric patients (<18 years) who underwent the Ross procedure between 1995 and 2022.
- Patients were divided into groups based on whether autograft reinforcement (subcoronary implantation or external support) was used.
- Kaplan-Meier survival and reintervention analyses were performed, with Cox regression identifying risk factors.
Main Results:
- Autograft reinforcement was associated with significantly improved long-term survival (97.1% at 5/10 years vs. 87.0% without reinforcement).
- No significant differences in autograft reintervention rates were observed between reinforced and non-reinforced groups.
- Right ventricle-pulmonary artery (RV-PA) reintervention-free survival was higher with homografts (96.9%) compared to xenografts (79.4%) at 5 years.
Conclusions:
- The Ross procedure in children yields excellent long-term outcomes with low autograft reintervention rates.
- Autograft reinforcement improves overall survival but does not significantly alter autograft-specific reintervention rates.
- Further multicenter studies are needed to validate findings on reinforcement techniques and RV-PA outcomes.
Objectives:
The Ross procedure with autograft reinforcement has been proposed as a strategy to prevent autograft failure in adults, but outcome data in children during somatic growth remain limited. We investigated long-term outcomes following an individualized autograft reinforcement protocol to evaluate survival and reintervention rates.
Methods:
Between January 1995 and December 2022, 233 patients <18 years [median age: 7 (1-13) years] underwent the Ross procedure, including 60 infants (26%). Most frequently free-root autograft implantation without reinforcement was performed (n = 156, 67%). Autograft reinforcement was applied in 77 patients (33%) using either subcoronary implantation (n = 65, 28%) or external prosthetic support (n = 12, 5%). Kaplan-Meier survival estimates were used for survival and reintervention analyses. Risk factors for reintervention were identified by Cox proportional hazards regression.
Results:
Reinforcement was associated with improved survival (5-year survival rates of 97.1% vs 87.0%, 10-year survival rates of 97.1% versus 86.99%, P = 0.017). No differences in autograft reintervention between the groups were found (1-year rates of 100% vs 99.4%, 5-year rates of 100%, P = 0.4852). Right ventricle-pulmonary artery (RV-PA) reintervention-free survival at 5 years was higher for homografts compared to xenografts (96.9% vs 79.4%, P < 0.001).
Conclusions:
The Ross procedure in children demonstrated excellent long-term outcomes with low autograft reintervention rates in both groups. Reinforcement was associated with improved long-term survival while autograft-related reinterventions did not differ significantly between groups. Older age at Ross and homograft use correlated with lower RV-PA reintervention risk. Multicentre evaluation of reinforcement techniques is required to assess the outcome differences observed in this single-centre experience.
