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Sarnaik KS, Hoenig SM, Bakir NH, Hammoud MS, Mahboubi R, Vervoort D, McCrindle BW, Welke KF, Karamlou T. Ross procedure or mechanical aortic valve, which is the best lifetime option for an 18-year-old? A decision analysis. JTCVS OPEN 2024; 17:185-214. [PMID: 38420529 PMCID: PMC10897596 DOI: 10.1016/j.xjon.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/22/2023] [Accepted: 10/23/2023] [Indexed: 03/02/2024]
Abstract
Objectives Identifying the optimal solution for young adults requiring aortic valve replacement (AVR) is challenging, given the variety of options and their lifetime complication risks, impacts on quality of life, and costs. Decision analytic techniques make comparisons incorporating these measures. We evaluated lifetime valve-related outcomes of mechanical aortic valve replacement (mAVR) versus the Ross procedure (Ross) using decision tree microsimulations modeling. Methods Transition probabilities, utilities, and costs derived from published reports were entered into a Markov model decision tree to explore progression between health states for hypothetical 18-year-old patients. In total, 20,000 Monte Carlo microsimulations were performed to model mortality, quality-adjusted-life-years (QALYs), and health care costs. The incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analyses was performed to identify transition probabilities at which the preferred strategy switched from baseline. Results From modeling, average 20-year mortality was 16.3% and 23.2% for Ross and mAVR, respectively. Average 20-year freedom from stroke and major bleeding was 98.6% and 94.6% for Ross, and 90.0% and 82.2% for mAVR, respectively. Average individual lifetime (60 postoperative years) utility (28.3 vs 23.5 QALYs) and cost ($54,233 vs $507,240) favored Ross over mAVR. The average ICER demonstrated that each QALY would cost $95,345 more for mAVR. Sensitivity analysis revealed late annual probabilities of autograft/left ventricular outflow tract disease and homograft/right ventricular outflow tract disease after Ross, and late death after mAVR, to be important ICER determinants. Conclusions Our modeling suggests that Ross is preferred to mAVR, with superior freedom from valve-related morbidity and mortality, and improved cost-utility for young adults requiring aortic valve surgery.
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Affiliation(s)
- Kunaal S Sarnaik
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Samuel M Hoenig
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Nadia H Bakir
- Department of Pediatric Cardiac Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miza Salim Hammoud
- Department of Pediatric Cardiac Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Rashed Mahboubi
- Department of Pediatric Cardiac Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karl F Welke
- Division of Pediatric Cardiothoracic Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC
| | - Tara Karamlou
- Department of Pediatric Cardiac Surgery, Cleveland Clinic, Cleveland, Ohio
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Cattapan C, Della Barbera M, Dedja A, Pavan P, Di Salvo G, Sabatino J, Avesani M, Padalino M, Guariento A, Basso C, Vida V. Mechanical and Structural Adaptation of the Pulmonary Root after Ross Operation in a Murine Model. J Clin Med 2022; 11:jcm11133742. [PMID: 35807025 PMCID: PMC9267924 DOI: 10.3390/jcm11133742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 01/25/2023] Open
Abstract
Background: The major limitation to the Ross operation is a progressive autograft dilation, possibly leading to reoperations. A murine model was created to evaluate pulmonary artery graft (PAG) adaptation to pressure overload. Methods: Lewis rats (n = 17) underwent heterotopic surgical implantation of a PAG, harvested from syngeneic animals (n = 17). A group of sham animals (n = 7) was used as a control. Seriated ultrasound studies of the PAG were performed. Animals were sacrificed at 1 week (n = 5) or 2 months (n = 15) and the PAG underwent mechanical and histopathological analyses. Results: Echography showed an initial increase in diameter (p < 0.001) and a decrease in peak systolic velocity (PSV). Subsequently, despite no change in diameter, an increase in PSV was observed (p < 0.01). After 1 week, the stiffness of the PAG and the aorta were similar, while at 2 months, the PAG appeared more rigid (p < 0.05). PAG’s histological analysis at 2 months revealed intimal hyperplasia development. The tunica media showed focal thinning of the elastic lamellae and normally distributed smooth muscle cells. Conclusions: We demonstrated a stiffening of the PAG wall after its implantation in systemic position; the development of intimal hyperplasia and the thinning of the elastic lamellae could be the possible underlying mechanism.
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Affiliation(s)
- Claudia Cattapan
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Mila Della Barbera
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (M.D.B.); (C.B.)
| | - Arben Dedja
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Piero Pavan
- Department of Industrial Engineering, University of Padua, 35131 Padua, Italy;
| | - Giovanni Di Salvo
- Pediatric Cardiology Unit, Department of Children and Woman’s Health, University of Padua, 35121 Padua, Italy; (G.D.S.); (J.S.); (M.A.)
| | - Jolanda Sabatino
- Pediatric Cardiology Unit, Department of Children and Woman’s Health, University of Padua, 35121 Padua, Italy; (G.D.S.); (J.S.); (M.A.)
| | - Martina Avesani
- Pediatric Cardiology Unit, Department of Children and Woman’s Health, University of Padua, 35121 Padua, Italy; (G.D.S.); (J.S.); (M.A.)
| | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Alvise Guariento
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (M.D.B.); (C.B.)
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35121 Padua, Italy; (C.C.); (A.D.); (M.P.); (A.G.)
- Correspondence: ; Tel.: +39-049-821-2410
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Egbe AC, Miranda WR, Bonnichsen CR, Jain CC, Crestanello JA, Francois C, Katta RR, Iftikhar M, Goda AY, Andi K, Gandhi S, Connolly HM. Prevalence and risk of progressive aortic aneurysm and dissection in adults with conotruncal anomalies. Eur Heart J Cardiovasc Imaging 2021; 23:1663-1668. [PMID: 34939103 DOI: 10.1093/ehjci/jeab273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/09/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Conotruncal anomalies share common embryogenic defects of the outflow tracts and great arteries, which result in a predisposition to aortic aneurysms. The purpose of this study was to describe the prevalence and risk of progressive aortic aneurysms in adults with conotruncal anomalies. METHODS AND RESULTS Retrospective study of adults with conotruncal anomalies that underwent cross-sectional imaging 2003-20. Aneurysm was defined as aortic root/mid-ascending aorta >2.1 mm/m2/>1.9 mm/m2, progressive aneurysm as increase by >2 mm, and severe aneurysm as dimension >50 mm. Of 2261 patients (38 ± 12 years; male 58%), 1167 (52%) had an aortic aneurysm, and 205 (14%) had a severe aortic aneurysm. Mean annual increase in aortic root/mid-ascending aorta was 0.3 ± 0.1 mm/0.2 ± 0.1 mm. The 3-, 5-, and 7-year cumulative incidence of the progressive aortic aneurysm was 4%, 7%, and 9%, respectively. The rate of aneurysm growth decreased with age, with no significant growth after age 40 years. There was an excellent correlation between aortic indices from cross-sectional imaging and echocardiography. Of 950 females, 184 had ≥1 pregnancy, and 81 (44%) of the 184 patients had aortic aneurysm prior to pregnancy. There was no aortic dissection or progression of the aortic aneurysm during pregnancy. Overall, there was no aortic dissection during 7984 patient-years of follow-up. CONCLUSIONS Aortic aneurysm was common in patients with conotruncal anomalies. However, the risk of progressive aneurysm or dissection was low. Collectively, these data suggest a benign natural history and perhaps a less frequent need for cross-sectional imaging. Further studies are required to determine the optimal timing for surgical intervention in this population.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - William R Miranda
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - Crystal R Bonnichsen
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - C Charles Jain
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905
| | - Christopher Francois
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Renuka R Katta
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - Momina Iftikhar
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - Ahmed Y Goda
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - Kartik Andi
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - Sangeetha Gandhi
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular MedicineMayo Clinic, Rochester, 200 First Street SW, MN, 55905, USA
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Leeds H, Ashfaq A, McGrath L, Dewey EN, Ungerleider RM, Shen I, Muralidaran A. Short- and Mid-Term Autograft Outcomes Following the Reinforced Ross Operation. World J Pediatr Congenit Heart Surg 2021; 13:38-45. [PMID: 34919480 DOI: 10.1177/21501351211061086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Ross operation for aortic valve replacement continues to be a controversial option because of concerns related to late autograft dilation and progressive neo-aortic insufficiency. In 2005, the reinforced Ross procedure was described at our institution to address this problem. We aim to analyze the short and mid-term outcomes following this procedure. METHODS This is a retrospective study of patients who underwent the reinforced Ross operation between 2004 and 2019. A comprehensive chart review was performed. Echocardiograms were independently reviewed by an adult congenital cardiologist. The time to reintervention was evaluated with a Kaplan-Meier curve. Analysis was conducted in JMP 15.1 (SAS Inc., Cary, NC). RESULTS Twenty-five patients underwent the reinforced Ross operation. Twenty-three patients (92%) had bicuspid aortic valve and the most common indication for surgery was a combination of aortic insufficiency and stenosis (n = 18, 72%). The mean follow-up was 6.1 ± 5.0 years. All patients were alive at the time of follow-up. Six patients (24%), from early in our experience, required subsequent aortic reintervention. Median time to reintervention was 41.8 months (0-81.5 months). Sixteen (64%) patients had less than moderate aortic insufficiency at last follow-up. Additionally, average aortic root measurements remained unchanged. CONCLUSIONS The reinforced Ross technique was initially proposed as a way to mitigate aortic root dilation seen in the traditional Ross procedure. Our experience suggests an associated learning curve with the majority of aortic reinterventions occurring within the first few years following surgery. Continued follow-up is warranted to assess its long-term durability and functionality.
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Affiliation(s)
- Hayden Leeds
- 6684Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Awais Ashfaq
- Heart Institute, 537912Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - Lidija McGrath
- Section of Adult Congenital Heart Disease, 89020Oregon Health & Science University, Portland, OR, USA
| | - Elizabeth N Dewey
- 6684Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | | | - Irving Shen
- Section of Pediatric and Congenital Cardiac Surgery, 20240Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
| | - Ashok Muralidaran
- Section of Pediatric and Congenital Cardiac Surgery, 20240Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
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Bichell DP. Autograft Root Dilation After the Ross Procedure Is Not Benign. World J Pediatr Congenit Heart Surg 2021; 12:516-517. [PMID: 34278869 DOI: 10.1177/21501351211015927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Autograft root dilation is common after the unsupported Ross procedure. In the absence of valvar incompetence, and with the perception that dissection is exceedingly rare, expectant management of autograft aneurysm is common practice. Autograft dissection may not be as rare as thought though, as at this point 7 case reports have accrued that describe autograft dissection requiring urgent operative intervention. All had a bicuspid native aortic valve. Bicuspid aortic valve has been shown to be associated with an intrinsic, histologically demonstrated pulmonary arteriopathy, possibly contributing to autograft root dilation and dissection. Autograft root dilation can no longer be regarded as benign, especially in patients with bicuspid aortic valve. Mounting evidence further validates the practice of externally supporting the Ross autograft. For patients who have had an unsupported Ross procedure, mounting evidence may support earlier intervention for autograft root dilation and aneurysm.
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Affiliation(s)
- David P Bichell
- Department of Cardiac Surgery, Monroe Carell, Jr. Children's Hospital, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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