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Mitchell ME, Woods RK, Geoffrion TR, Sow M. Late Pulmonary Autograft Dilation: Can We Make a Good Operation Great? The Supported Ross. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2024; 27:47-51. [PMID: 38522872 DOI: 10.1053/j.pcsu.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/12/2024] [Accepted: 01/13/2024] [Indexed: 03/26/2024]
Abstract
The Ross procedure is an excellent option for aortic valve replacement resulting in outstanding hemodynamic performance and the ability to avoid systemic anticoagulation. The long-term durability of the autograft is generally good but concerns for later aortic root dilation with ensuing neoaortic insufficiency have prompted efforts to stabilize the autograft, root, sinuses and Sino-tubular junction in order to delay or entirely avoid late reinterventions on the neoaortic root. We have employed an inclusion technique, supporting the Auto-graft in a Terumo Gelweave™ Valsalva graft. We performed a retrospective study of all 129 patients undergoing the Ross procedure from 1992 to 2019 at Children's Wisconsin. Fifty-one underwent the supported Ross (SR) and 78 underwent unsupported Ross (UR). Structured clinical data was collected and echocardiograms were reviewed. Median follow-up was 4.9 years (up to 22.6 years) for UR patients and 3.6 years (up to 11.4 years) for SR patients. In order to provide a fair comparison, we sub -analyzed patients aged 10 to 18 years who underwent the Ross procedure, 16 who underwent the UR and 18 patients who underwent the SR. Change in aortic annulus diameter (P = 0.002), aortic sinus diameter (P = 0.001) change in left ventricular function (P = 0.039) and change in aortic insufficiency (P = 0.008) were all worse in UR. The SR is simple, reproducible, and predictable. It seems to prevent change in annulus diameter, sinus diameter and to reduce late neoaortic insufficiency. Longer follow-up with a larger group of patients is required to draw definitive conclusions.
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Affiliation(s)
- Michael E Mitchell
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wisconsin; Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin.
| | - Ronald K Woods
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wisconsin; Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Tracy R Geoffrion
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wisconsin; Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Mami Sow
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
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El Sherif N, Dearani JA, Connolly HM, Bagameri G, Pochettino A, Stulak JM, Stephens EH. Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era. Ann Thorac Surg 2023; 115:633-639. [PMID: 35644264 DOI: 10.1016/j.athoracsur.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/04/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Ross procedure has several advantages, but the need for reintervention is inevitable. The aim of this study was to examine the complexity and outcomes of reoperation after the Ross procedure. METHODS Retrospective chart review was performed of patients with a prior Ross procedure who underwent reoperation at our institution from September 1991 to January 2021. Demographic, echocardiographic, surgical, and perioperative data were collected. Descriptive statistical and regression analyses were performed. RESULTS A total of 105 patients underwent a reoperation at Mayo Clinic after the initial Ross procedure performed at our institution (n = 16; 16.2%) or elsewhere (n = 83; 83.8%). Mean age at the Ross procedure was 27 ± 17 years, and mean age at reoperation at our institution was 37 ± 19 years. Indications for surgical procedure varied, but 64% had autograft regurgitation as 1 of their indications for reoperation. Autograft interventions were performed in 78 patients (74.2%). Pulmonary valve or conduit replacement was performed in 56 patients (53.3%). Double root replacement was performed in 11 patients (10.5%). Aortic reconstruction was performed in 37 patients (38.4%). There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%). Patients with ejection fraction <30% on preoperative echocardiography had shorter duration between the Ross procedure and subsequent reoperation (P = .03). CONCLUSIONS Reoperations after the Ross procedure are performed for a wide range of indications, with most due to autograft dysfunction. The number of early deaths is not low. Reoperation after the Ross procedure should be advised before left ventricular systolic dysfunction.
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Affiliation(s)
- Nibras El Sherif
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Sow M, Ginde S, Bartz P, Cohen S, Gerardin J, Kuhn E, Jaquiss R, Litwin SB, Woods RK, Hraska V, Tweddell JS, Mitchell ME. The Supported vs Unsupported Ross in Pediatric Patients: Neoaortic Root and Ventricular Function. Ann Thorac Surg 2023; 115:453-460. [PMID: 35820490 DOI: 10.1016/j.athoracsur.2022.05.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/14/2022] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The supported Ross is used to mitigate the neoaortic root dilation that has been described with the unsupported Ross. There is limited literature assessing the efficacy of the supported Ross in young patients. In this study, the fate of the neoaortic root was compared in the supported and unsupported Ross procedure in adolescent patients. METHODS A retrospective review was performed of patients who underwent the Ross procedure between 1996 and 2019. An analysis was conducted of patients aged 10 to 18 years who underwent the supported and unsupported Ross operation, without a Konno enlargement, to assess for longitudinal echocardiographic changes. Given differences in follow-up time, both regression analysis and Mann-Whitney nonparametric tests were used to correct for time from discharge to most recent follow-up. RESULTS The median follow-up time for supported and unsupported Ross patients without a Konno enlargement was 2.90 years (0.21-13.03 years) and 12.13 years (2.63-19.47 years), respectively. Unsupported Ross patients experienced a higher rate of change per year in the aortic annulus (P = .003 and P = .014) and aortic sinus (P = .002 and P = .002) diameters, respectively. There was no significant difference in the rate of change of end-diastolic left ventricular internal diameter (P = .703 and P = .92) and aortic insufficiency (P = .687 and P = .215) between the supported and unsupported Ross patients. CONCLUSIONS Progressive dilation of the neoaortic root in unsupported Ross patients is significantly mitigated with the supported Ross with excellent stability. The supported Ross is safe and effective and may play an increasing role in the management of children with aortic disease.
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Affiliation(s)
- Mami Sow
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Salil Ginde
- Department of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Peter Bartz
- Department of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Scott Cohen
- Department of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Gerardin
- Department of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Evelyn Kuhn
- Outcomes Department, Children's Wisconsin, Milwaukee, Wisconsin
| | - Robert Jaquiss
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Medical Center, Dallas, Texas
| | - S Bert Litwin
- Division of Pediatric Congenital Cardiac Surgery, Department of Surgery, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Pediatric Congenital Cardiac Surgery, Department of Surgery, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Viktor Hraska
- Division of Pediatric Congenital Cardiac Surgery, Department of Surgery, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Michael E Mitchell
- Division of Pediatric Congenital Cardiac Surgery, Department of Surgery, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin.
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Guirgis L, Hascoet S, Van Aerschot I, Radojevic J, Ly M, Cohen S, Belli E. Outcomes after the Ross procedure with pulmonary autograft reinforcement by reimplantation. JTCVS Tech 2023; 17:121-8. [PMID: 36820346 DOI: 10.1016/j.xjtc.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/31/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022] Open
Abstract
Background Pulmonary autograft reinforcement to prevent dilatation and subsequent neo-aortic valve regurgitation has been reported; however, data on long-term function of the neo-aortic valve after this modified Ross procedure are lacking. Our objective here was to assess long-term outcomes of the modified Ross procedure with autograft reinforcement using the reimplantation technique. Patients The outcomes of 61 consecutive patients managed using the Dacron-conduit reinforced Ross procedure between 2009 and 2021 were reviewed. Most patients had a unicuspid or bicuspid aortic valve (n = 52; 85%), predominant aortic valve regurgitation (n = 42; 77%), and >30 mm dilatation of the ascending aorta (n = 33; 54%). A prior aortic valve procedure was noted in 47 patients (77%) patients, including 38 (62%) with surgical repair and 9 (15%) with balloon dilatation. The pulmonary autograft was reimplanted within a Dacron conduit with a median diameter of 25.6 mm (range, 20-30 mm) using the David valve-sparing aortic root replacement technique. Results All patients survived. The median age at surgery was 16.8 years (range, 6-38 years). Neo-aortic valve replacement was required in 3 patients (4.9%; 95% CI, 0.34%- 12.7%) because of infective endocarditis, left ventricular false aneurysm, and leaflet perforation, respectively; the repeat procedure was done early in 2 of these patients (2 of 61; 3%). Six patients required right ventricular outflow conduit replacement, 5 by surgery and 1 percutaneously. The median duration of follow-up was 90 months (range, 10-124 months). The 5- and 10-year rates of reintervention-free survival were 84.3% (95% CI, 74%-95%) and 81.6% (95% CI, 72%-93%), respectively, and 5-year survival without aortic reintervention was 94.5% (95% CI, 88%-100%), with little change at 10 years. No patients experienced deterioration of initial neo-aortic valve function (ie, regurgitation or stenosis). Conclusions Autograft reinforcement using the reimplantation technique allowed expansion of Ross procedure indications to all patients requiring aortic valve replacement and prevented neo-aortic root dilatation. Failures were uncommon. Long-term follow-up data showed stable neo-aortic valve function.
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DeCampli WM. Will we work out the Ross dilemma in 30 minutes?-Or 30 years? World J Pediatr Congenit Heart Surg 2022; 13:175-177. [PMID: 35238699 DOI: 10.1177/21501351221075839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- William M DeCampli
- Division of Cardiovascular Surgery, Arnold Palmer Hospital for Children, Orlando, FL, USA; Department of Clinical Sciences, University of Central Florida College of Medicine, Orlando, FL, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hassler KR, Dearani JA, Stephens EH, Pochettino A, Ramakrishna H. The Ross Procedure: Analysis of Recent Outcomes Data. J Cardiothorac Vasc Anesth 2021; 36:3365-3369. [PMID: 34895964 DOI: 10.1053/j.jvca.2021.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Varrica A, Satriano A, Frigiola A, Giamberti A. AUTOGRAFT WRAPPING REINFORCEMENT IN ADOLESCENTS UNDERWENT ROSS OPERATION: A TAILORED COAT. Ann Thorac Surg 2021; 114:866-871. [PMID: 34217690 DOI: 10.1016/j.athoracsur.2021.05.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/24/2021] [Accepted: 05/24/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Ross operation is a good surgical option for pediatric population with aortic valve disease. However, the need for reoperation due to aortic root dilatation remains the principal limitation of this procedure. We report a small series of adolescents who underwent the Ross operation with goretex membrane reinforcement to avoid the progressive dilatation of the neo-aortic root. METHODS Between March 2002 and March 2010, 15 adolescent patients underwent a modified Ross procedure with the autograft wrapping with Gore® Preclude® pericardial membrane 0.1 mm. Follow-up was performed by clinical and echocardiographic controls. RESULTS The mean age of these patients was 15 ± 1.4 years. The mean aortic cross-clamp time was 130 ± 17 minutes. The mean cardiopulmonary bypass time was 187 ± 27 minutes. There was no hospital mortality. The mean follow-up was 15 ± 2.5 years (range 9.7-17.7 years). During the follow-up one patient required aortic valve reoperation for cusps prolapse. The mean diameters of annulus (22.8 ± 1.8 mm vs 23.3 ± 1.5 mm, p=0.12), aortic root (27.4±1.4 mm vs 28.2 ± 0.8 mm, p=0.09) and sino-tubular junction (24.3 ± 1.1 mm vs 25.1 ± 0.7 mm, p=0.11) were not statistically different between discharge and follow up. CONCLUSIONS The wrapping reinforcement autograft in Ross procedure with goretex membrane is simple, safe and does not require significant additional time. Our results showed good early and long-term outcomes in terms of reoperation, aortic root dilatation and aortic valve degeneration.
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Affiliation(s)
- Alessandro Varrica
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy.
| | - Angela Satriano
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy
| | - Alessandro Frigiola
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy
| | - Alessandro Giamberti
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato M.se, (Mi), Italy
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Buratto E, Konstantinov IE. Highlights in congenital cardiothoracic surgery: 2020-2021. J Thorac Cardiovasc Surg 2021; 162:349-52. [PMID: 34045057 DOI: 10.1016/j.jtcvs.2021.04.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/15/2022]
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Affiliation(s)
- James S Tweddell
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
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Kumar RS. Commentary: "Growing" Understanding of the Autograft Root. Semin Thorac Cardiovasc Surg 2020; 32:507-508. [PMID: 32446919 DOI: 10.1053/j.semtcvs.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ram S Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital of Los Angeles, Los Angeles, California.
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