Ross Procedures in Children With Previous Aortic Valve Surgery.

Ross Procedures in Children With Previous Aortic Valve Surgery.

Buratto E, Wallace FRO, Fricke TA, Brink J, d’Udekem Y, Brizard CP, Konstantinov IE.

J Am Coll Cardiol. 2020 Sep 29;76(13):1564-1573. doi: 10.1016/j.jacc.2020.07.058.

PMID: 32972534


Take Home Points:


  • Initial Ross procedure in infancy may be associated with relatively higher mortality, justifying initial attempts to defer operation with aortic valve repairs, even if eventual replacement is necessary.
  • Secondary Ross after initial valve repair is associated with superior long-term survival and freedom from autograft reoperation.
  • Delaying the Ross operation by performing initial valve repair, when possible, may be preferred to initial Ross in infant patients.


Commentary from Dr. Barry Deatrick (Baltimore, MD, USA), section editor of Congenital Heart Surgery Journal Watch:  Aortic valve disease requiring surgical repair in childhood can be a challenge, with limited options available for replacement.  Although the Ross procedure offers the best long-term freedom from reoperation in neonates and infants, the long term freedom from reintervention in some series remain disappointing, with high mortality rates in infants (16 – 22%).  Because of this, some centers advocate an approach that of initial aortic valve repair, whenever possible, followed by a secondary Ross procedure when necessary.  The goal of this retrospective analysis as to determine if there was a difference in outcome between the Ross operation when performed as a primary operation and when performed as a reoperation.


The authors retrospectively analyzed 541 aortic valve operations in their institution, 344 of which were aortic valve repairs, and 140 of which were Ross procedures.  68 (49%) of the Ross procedures took place after previous valve repairs, and 72 (51%) took place as the primary operation.   Patients undergoing a primary Ross were older (8.6 years vs 7 years), and had higher weights (28.9 kg vs. 19.7 kg) although these differences weren’t significant.  The early mortality was 5.6% (n = 4 of 72) in those undergoing primary Ross procedure, compared with 4.4% (n = 3 of 68) in those undergoing secondary Ross procedure.  This difference was not statistically significant (p = 1.0).  Freedom from reoperation at 10 and 15 years was 68.3% and 48.5% in those undergoing primary Ross procedure.  In those who underwent secondary Ross procedure, freedom from reoperation at 10 and 15 years was 62.2% and 47.0% respectively.  Again, this difference was not statistically significant.   In the  propensity-matched groups, however, survival at 10 and 15 years was 90.0% and 82.6% in the primary Ross procedure group, compared with 96.8% at both 10 and 15 years in the secondary Ross procedure group. In the propensity-matched analysis, this difference was statistically significant (p = 0.04).


The mechanisms for the improved survival and freedom from reoperation are discussed briefly, including possible stabilization of the autograft from postoperative scar and adhesion formation, but this was just postulated rather than investigated.  None were investigated in this retrospective review.


The authors concluded that secondary Ross procedure performed after initial aortic valve surgery achieves superior long-term survival and freedom from autograft reoperation compared with primary Ross procedure. A strategy of initial aortic valve surgery followed by delayed Ross procedure may provide better long-term survival and freedom from autograft reoperation in aortic valve disease in children.