小児集団における全根治的ロス手術の30年の経験 - タイミングが重要！
Viktoria H M Weixler1,2, Alison J Howell3, Bana Samman1
1Division of Cardiovascular Surgery, The Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada.
Objective:
The optimal timing of Ross procedure in pediatric patients remains unclear. We aimed to analyze how age, diagnosis, autograft support, and Konno-incision impact outcome.
Methods:
Patients (0-18 years) undergoing primary/secondary Ross/Ross-Konno from August 1993 to November 2023 were included. Mortality, autograft replacement rate, and greater than mild autograft regurgitation were analyzed in the full cohort and subgroups (age, diagnosis, primary/secondary Ross, Ross/Ross-Konno, autograft support) using time-to-event methods. Propensity-score matching was performed to adjust for differences in baseline characteristics of patients undergoing supported/nonsupported Ross procedures.
Results:
In total, 196 patients underwent Ross/Ross-Konno procedures (N = 117/79; 60/40%) with median age/weight of 9.4 years [interquartile range, 3.4-14.1 years]/31.7 kg [12.9-57 kg] and median follow-up of 8.8 years [1.6-14.8 years]. Twenty-year freedom from death, autograft replacement rate, and rate of greater than mild autograft regurgitation was 88.7% (95% confidence interval, 79.8%-93.8%), 13.2% (7.1%-24.7%), and 17.7% (11.3%-27.8%), respectively. Lowest 20-year freedom from death was observed among neonates/infants 47.6% (7.5%-80.8%)/58.9% (34.5%-76.8%) compared with older patients (97.6%; 90.6%-99.4%, P < .001). In total, 83.3% of all deceased neonates/infants had associated mitral valve disease. Patients with isolated aortic valve stenosis and/or Konno-incision were at greater mortality risk (P = .02). 20-year autograft replacement rate was highest among adolescents (12-18 years): 30.7% (15.5-60.9), without statistical significance (P = .08), and greater in secondary Ross: 23.8% (11.4-49.7, P = .03). Matched pairs (supported vs nonsupported Ross, n = 30 each) did not show differences in primary outcomes.
Conclusions:
The Ross procedure in pediatric patients demonstrated good long-term outcomes. Mortality risk is greater in neonates/infants and patients with isolated aortic stenosis. Adolescent patients/patients undergoing secondary Ross procedures were associated with greater autograft replacement rates.
