Regurgitant jet type predicts autograft outcomes after the Ross procedure in patients with congenital heart disease

The prognostic significance of regurgitant jet patterns after Ross procedure are still poorly understood. Our aim was to characterize the morphology and progression of autograft regurgitation (AR) and to evaluate their influence on autograft durability.

Consecutive patients ≥12 years undergoing a Ross procedure using the full-root implantation technique between 1998 and 2024 were included. Comprehensive echocardiographic assessments were performed intraoperatively and during follow-up. End points included autograft valve reoperation, evolution of regurgitation and autograft dimensions. A time-to-event analysis was conducted among patients who developed mild or greater regurgitation during follow-up.

A total of 131 patients were included. Median age was 17.2 years (range, 14.5-24 years). Intraoperatively, 1 patient had moderate or greater AR. Intraoperative detection of mild or greater eccentric jet (n = 16) conferred a higher risk of 10-year autograft reoperation compared with central (n = 16) (44.4% [95% CI, 18.3%-100.0%] versus 9.1% [1.4%-58.9%]; P < .05). In patients without intraoperative AR, this risk was 0%. At median follow-up of 5.6 years (range, 2.2-11.8 years), 66 patients developed mild or greater AR: 23 eccentric and 43 central jets. Overall, eccentric jets were associated with polyethylene terephthalate full support (74% with annular support vs 4% with unsupported 22%; P < .01), mostly located around the right coronary commissures. Detected during follow-up, eccentric jets were associated with reoperation (35.4% [95% CI, 15.7%-79.8%] vs central jet 4.5% [95% CI, 0.7%-30.8%]; P < .05). In unsupported Ross, AR severity was associated with progressive annular and root dilatation.

Absence of intraoperative AR predicted excellent long-term outcomes. Eccentric AR, suggestive of leaflet dysfunction, was strongly associated with reoperation, whereas central AR tracked with gradual annular/root dilation. Even mild, intraoperative eccentric AR should prompt immediate surgical correction.