Midterm Outcomes of the Supported Ross Procedure in Children, Teenagers and Young Adults

Midterm Outcomes of the Supported Ross Procedure in Children, Teenagers and Young Adults.

Riggs KW, Colohan DB, Beacher DR, Alsaied T, Powell S, Moore RA, Ginde S, Tweddell JS.

Semin Thorac Cardiovasc Surg. 2019 Dec 18. pii: S1043-0679(19)30391-0. doi: 10.1053/j.semtcvs.2019.10.020. [Epub ahead of print]

PMID: 31863831

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Take Home Points:

  • The Ross procedure is an excellent option for aortic valve replacement in children and young adults, but dilation of the pulmonary autograft can lead to the need for further surgery.
  • The supported Ross procedure has been designed to minimize the risk of pulmonary autograft dilation and this single-center review supports this decreased risk with mid-term data on 40 patients.

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Commentary from Dr. Timothy Pirolli (Dallas), section editor of Congenital Heart Surgery Journal Watch: The Ross procedure involves replacing the aortic valve with a pulmonary autograft and then using a pulmonary homograft for replacement of the pulmonary valve and main pulmonary artery. This procedure has proven very effective for younger patients and avoids the need for anticoagulation. However, the pulmonary autograft can dilate over time creating neoaortic root dilation and aortic regurgitation, necessitating further surgery. In 2005, a modified version of the Ross procedure was described by Ungerleider et al. The modification involved the use of a slightly oversized Dacron tube graft to surround and support the pulmonary autograft to minimize the ability of the autograft to dilate with time. The mid-term results of the supported Ross procedure from two centers are presented here.

 

The authors used retrospective data from Cincinnati Children’s and Children’s Hospital of Wisconsin to evaluate 40 patients’ outcomes from 2005-2018. The study does not explicitly mention the detail that the senior author worked at both institutions during this time period and it does not specify how many surgeons performed the surgeries during this time period. The outcomes examined included survival, cardiac reintervention and aortic dimensions from serial echocardiograms. The patients ranged in ages from 10-35 years old (median age of 16 years) and median length of follow-up was 3.5 years (1.4-5.6 years) with only 3 patients followed for >10 years.

 

The graph depicting root dilation in this cohort is shown in graph 1 below. A z-score >2.5 was used as the cut off to define > mild dilation of the neoaortic root. Figure 1 gives a schematic drawing of the supported Ross procedure. The key component to the surgery is that the graft was sized ~ 4mm greater than the size of the pulmonary autograft. To allow adequate neoaortic growth, this limited the use of the supported Ross to patients older than 10-12 years. The comparison between average discharge and follow-up echo measurements are in Figure 3. There were no deaths during the study period. Five patients required reintervention, but only one of those required an aortic valve replacement.

 

This study supports the use of supported Ross in select patients above a certain age for aortic valve replacement. The mid-term results are good. The long-term results are obviously needed, but this will take many years to obtain. The size cutoff of a pulmonary autograft of 25 mm is helpful for practitioners seeking to utilize this procedure on their own patients. This can obviously be elucidated clearly preoperatively using CT scan or possibly echocardiography. The major questions that are left after reviewing this paper is are these results durable long-term and are they able to be duplicated in the hands of other surgeons? Certainly, these results are encouraging and should serve as a solid foundation for future studies and the care of young patients with aortic valve disease that requires valve replacement.

 

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