Asian Cardiovasc Thorac Ann 2007;15:30-34
© 2007 Asia Publishing EXchange Ltd
The Ross Operation: Clinical Results and Echocardiographic Findings
Mehrdad Salehi, MD,
Roya Sattarzadeh, MD,
Ali Akbar Soleimani, MD,
Hassan Radmehr, MD,
Jalil Mirhosseini, MD,
Mehdi Sanatkar Far, MD
Department of Cardiac Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
For reprint information contact: Roya Sattarzadeh, MD, Tel: 98 21 4406 5893, Fax: 98 21 4406 4531, Email: satarzad{at}sina.tums.ac.ir, 1419731351-Imam Khomeini Hospital, Keshavarz Blvd., Tehran, Iran.
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ABSTRACT
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Between November 2001 and September 2004, 80 patients aged 11 to 56 years (mean, 27.6 years) underwent the Ross operation. The mean preoperative New York Heart Association functional class was 2.37 ± 0.72, and the mean ejection fraction was 52.8% ± 16%. Aortic involvement included stenosis in 19 (24%) patients, regurgitation in 22 (28%), and both in 39 (49%). Root replacement was the technique used in all cases. The mean hospital stay was 5 days, and 74 patients (93%) were followed up for 4 – 48 months. Four-year actuarial survival rate was 96.25%. Postoperative echocardiography revealed no pulmonary autograft insufficiency in 50 patients (63%), trivial to mild insufficiency in 22 (28%), moderate insufficiency in 2 (3%), and severe insufficiency in one (1%). Two patients required autograft re-intervention. Postoperative echocardiography of the pulmonary homograft valve showed severe stenosis (peak gradient > 50 mm Hg) in 2 patients, and moderate stenosis (peak gradient 25–50 mm Hg) in one. The mean postoperative left ventricular ejection fraction was 51.4%. The Ross operation can be considered an elegant alternative to prosthetic valves in the treatment of aortic valve diseases in developing countries.
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INTRODUCTION
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In 1986, the advent of the root replacement technique for aortic valve replacement led to increasing use of the Ross operation. The 20-year follow-up report from the pioneer series in 1997, and other long-term reports renewed international interest in this technically demanding procedure, changing the concept from an experimental treatment to a real clinical option.1,2 The low procedure-related morbidity and mortality, ability to grow, outstanding hemodynamics, resistance to infection, absence of hemolysis, lack of thrombogenicity, and silent performance of the pulmonary autograft make it a good candidate for the ‘ideal valve substitute’.3–5 In this report, we describe our experience of replacement of aortic valves with pulmonary autografts, and the results in 80 consecutive patients.
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PATIENTS AND METHODS
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Between November 2001 and September 2004, 80 consecutive patients (mean age, 27.6 years; range, 11 to 56 years) underwent the Ross operation (Figure 1
). Aortic involvement detected in our patients comprised stenosis in 19 (24%), regurgitation in 22 (28%), and both lesions in 39 (49%). The causes of aortic valve disease are listed in Table 1. Previous procedures had been performed in 10 patients: surgical valvotomy/valvuloplasty in 3, ventricular septal defect closure in one, aortic valve replacement in 5, closure of a patent ductus arteriosus in 2, repair of aortic coarctation in 3, and atrial septal defect closure in one. Preoperatively, the mean New York Heart Association (NYHA) functional class was 2.37 ± 0.72, and the mean ejection fraction was 52.8% ± 16%.
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Figure 1. The number of Ross procedures performed each year at the Imam Khomeini Medical Center, Tehran University of Medical Sciences.
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Elective surgery was performed in all except one patient who was undergoing chemotherapy for acute myelocytic leukemia and had large vegetations on the aortic leaflets detected by echocardiography; this patient underwent urgent surgery. After implantation of the pulmonary autograft into the aortic root and reimplantation of the coronary ostia, the right ventricular outflow tract was replaced with a cryopreserved homograft valve in all patients. The mean aortic cross clamp time was 129 min (range, 90 to 191 min). Associated procedures were carried out in 13 patients: the Ross-Konno procedure, ascending aortic replacement, tricuspid valve commissurotomy, myomectomy of the interventricular septum, repair of a pulmonary homograft leaflet, and mitral valve commissurotomy in one patient each, tricuspid valve annuloplasty with the DeVega procedure in 2, ventricular septal defect closure in 2, and subaortic membrane resection in 3. In 18 patients (23%) with aortic insufficiency and 8 (10%) with aortic stenosis, inotropic support was used perioperatively.
Transthoracic M-mode, two-dimensional, color-flow, and Doppler echocardiograms were obtained in all patients before surgery, at the time of discharge, 1 and 6 months later, and annually thereafter. Transesophageal echocardiography was performed intraoperatively to assess the function of the autograft and homograft valves. All information from the echocardiographic assessment of autograft valve function, homograft valve function, ventricular size and function, and autograft dimensions was collected in a database. The degrees of regurgitation in autografts and homografts were graded as none or trivial, mild, moderate, and severe. The peak flow velocities across both semilunar valves were also assessed. All complications were defined and reported according to the guidelines for reporting morbidity and mortality after cardiac valve operations.6
The collected data were analyzed statistically with SPSS software version 11.0 (SPSS, Inc., Chicago, IL, USA). Variables are shown as mean ± standard deviation. Continuous variables were compared using the two-tailed paired Student’s t test. Discrete variables were compared using the chi-squared test and Fisher’s exact test. Midterm follow-up results were calculated using the Kaplan-Meier method.
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RESULTS
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The mortality rate was 3.75% (3/80 patients). One patient suffered cardiac death due to myocardial ischemia in the operating room, and 2 others died during their hospital stay (one from cerebral hemorrhage and the other from low output syndrome). The mean hospital stay was 5 ± 2.4 days (range, 4–31 days). Seventy-four patients (93%) were followed up for a mean of 17 months (range, 4 – 48 months). Four-year actuarial survival was 96.25% (Figure 2). On follow-up, 72 (90%) survivors were in NYHA class I, and 2 (3%) were in NYHA class II.
Postoperative echocardiography revealed no pulmonary autograft insufficiency in 50 patients (63%), trivial to mild insufficiency in 22 (28%), moderate insufficiency in 2 (3%), and severe insufficiency in one (1%). Two patients (3%) required autograft re-intervention: one underwent redo surgery with a mechanical valve due to structural valve deterioration; and another underwent aortic valve replacement with a prosthetic valve one year after the first procedure, due to pseudoaneurysm of the neoaorta. In both cases, the native valves were tricuspid. The cumulative 48-month actuarial disease-free rate of re-intervention was 97% (Figure 3). During follow-up, none of the patients with a bicuspid aortic valve showed pulmonary autograft insufficiency. Postoperative echocardiography of the pulmonary homograft valve showed severe stenosis (peak pressure gradient > 50 mm Hg) in 2 patients (3%) and moderate stenosis (peak pressure gradient 25–50 mm Hg) in one. The peak transpulmonary pressure gradients were approximately 20–25 mm Hg in 10 patients, and < 10 mm Hg in the others. All patients remained free from pulmonary homograft re-intervention. No hemolysis, thrombosis, thromboembolism, endocarditis, or major hemorrhagic events were detected in any patient during follow-up. Preoperative and postoperative echocardiography data are listed in Table 2. The preoperative pulmonary and aortic valve annular diameters were 22.4 ± 2.6 mm and 23.9 ± 3.0 mm, respectively.
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DISCUSSION
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Clinicians taking care of children or young adults with significant aortic valve disease often face the difficult dilemma of when to operate and what graft material to implant. The choice is usually between mechanical prostheses, xenografts, and homografts. Mechanical prostheses are long lasting but require anticoagulation, carry a continuous infection threat, and may display suboptimal hemodynamic performance, particularly on exertion.7 Xenografts do not require anticoagulation but often exhibit poorer hemodynamic performance than mechanical prostheses and frequently degenerate, particularly in young patients.7,8 Homografts have limited durability, do not grow, and hence often require re-operation. Due to these challenges, the decision to operate is often delayed, particularly in pediatric patients who are exposed to the risk of permanent left ventricular damage. Large-scale clinical studies indicate that the Ross procedure is safe, with favorable short and long-term results.7,9,10 Our data are in agreement with these reports. The increased availability of cryopreserved homografts due to the development of the Iranian Tissue Bank at Imam Khomeini Hospital, and increasing familiarization with the surgical techniques has turned this intervention into a real option in our country. On the other hand, the technical complexity of the procedure and insufficient knowledge of surgeons and cardiologists has led to many potential candidates being precluded from the benefits of the Ross procedure.
In our series, the hospital mortality was quite low (3.75%) and there were no thromboembolic events or endocarditis. Although attractive, the concept that progressive dilatation of the annulus after root replacement represents growth, and not a pathologic process that could lead to the development of subsequent valvular regurgitation, remains speculative. In our study, dilation of the sinus of Valsalva of the pulmonary autograft occurred immediately after surgery, but annulus dilation and progressive autograft regurgitation were not detected during follow-up. Aortic peak pressure gradients were always < 5 mm Hg, which were much lower than those previously reported for mechanical valves and bioprostheses.8,11
Pulmonary autografts offer superior durability compared to other biological substitutes, especially in young patients.12,13 The pulmonary autograft has also shown an outstanding ability to adapt to intense physical activity.14 Furthermore, the Ross procedure is considered to be a cost-effective option.15 In fact, it is recommended by the American Heart Association as the operation of choice for young adults, and especially for children and women of childbearing age.16 In this study, some patients were nearly 60 years old. We believe that selected patients over 50 years old could benefit from the Ross operation.13,17 Older patients show an ameliorated immune reaction against the homograft, and they have been found to fare better in the medium term.18 Although formal studies are lacking, we believe that strict blood pressure control (< 130/75 mm Hg) is important to prevent late dilatation of the autograft.
To prevent autograft dysfunction, some technical modifications have been adopted. A pericardial strip has been used in the inflow suture line, although we expect it to be more hemostatic than supportive.13 The fate of the homograft valve is an unresolved issue. Among the survivors in our series with pulmonary homograft valves, high transpulmonary pressure gradients (> 70 mm Hg) developed in 2 patients during mid-term follow-up. To date, none have required re-intervention for this reason, but we believe that detection of the risk factors and prevention and treatment of this complication must be elucidated if we wish to extend this technique to the majority of candidates. Rubay and colleagues19 demonstrated that the Ross procedure permitted recovery of left and right ventricular function, and improved NYHA functional class, particularly when it had been altered by long-standing aortic regurgitation.
In our study, the indication for the Ross procedure was aortic valve endocarditis in 15 patients (19%), and there were very good results in these patients. We consider the Ross operation to be the procedure of choice in cases of aortic valve endocarditis. There was a greater need for perioperative inotropic support in aortic valve insufficiency compared with aortic valve stenosis (18 patients with insufficiency vs 8 with stenosis), and this suggests that the early postoperative outcome of the Ross operation is better in patients with aortic valve stenosis rather than regurgitation. Two of our patients became pregnant after the Ross operation. No pulmonary autograft or homograft failure occurred during their pregnancies. In this series, the results of the Ross operation in patients with a bicuspid aortic valve were excellent, and we recommend that those with a bicuspid aortic valve should not be deprived of the benefits of this procedure.
Our experience with the Ross operation suggests that replacement of the aortic valve with a pulmonary autograft can be performed safely with low mortality and morbidity rates. This procedure does not require permanent anticoagulation and is associated with low incidences of endocarditis, thromboembolism, and degeneration. It constitutes an elegant alternative to prosthetic valve replacement in the treatment of aortic valve diseases.
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ACKNOWLEDGMENTS
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We take this opportunity to pay tribute to our late professor, Hamid Mirkhani, who performed the first Ross procedure in Iran and also did most of the cases herein reported, we also thank the Iranian Tissue Bank, Imam Khomeini Hospital, Tehran University, for its contribution by supplying high quality homografts.
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REFERENCES
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- Chambers JC, Somerville J, Stone S, Ross DN. Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series. Circulation 1997;96:2206–14.[Abstract/Free Full Text]
- Matsuki O, Okita Y, Almeida RS, McGoldrick JP, Hooper TL, Robles A, et al. Two decades’ experience with aortic valve replacement with pulmonary autograft. J Thorac Cardiovasc Surg 1988;95:705–11.[Abstract]
- Simon P, Aschauer C, Moidl R, Marx M, Keznickl FP, Eigenbauer E, et al. Growth of the pulmonary autograft after the Ross operation in childhood. Eur J Cardiothorac Surg 2001;19:118–21.[Abstract/Free Full Text]
- Legarra JJ, Concha M, Casares J, Merino C, Munoz I, Alados P. Left ventricular remodeling after pulmonary autograft replacement of the aortic valve (Ross operation). J Heart Valve Dis 2001;10:43–8.[Medline]
- Niwaya K, Knott-Craig CJ, Santangelo K, Lane MM, Chandrasekaran K, Elkins RC. Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg 1999;67:1603–8.[Abstract/Free Full Text]
- Edmunds LH Jr, Clark RE, Cohn LH, Grunkemeier GL, Miller DC, Weisel RD. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Eur J Cardiothorac Surg 1996;10:812–6.[Abstract]
- Laske A, Jenni R, Maloigne M, Vassalli G, Bertel O, Turina MI. Pressure gradients across bileaflet aortic valve by direct measurement and echocardiography. Ann Thorac Surg 1996;61:48–57.[Abstract/Free Full Text]
- Jaffe WM, Coverdale HA, Roche AH, Whitlock RM, Neutze JM, Barratt-Boyes BG. Rest and exercise hemodynamics of 20 to 23 mm allograft, Medtronic Intact (porcine), and St. Jude Medical valves in the aortic position. J Thorac Cardiovasc Surg 1990;100:167–74.[Abstract]
- Elkins RC, Santangelo K, Randolph JD, Knott-Craig CJ, Stelzer P, Thompson WM Jr, et al. Pulmonary autograft replacement in children. The ideal solution? Ann Surg 1992;216:363–71.[Medline]
- Elkins RC, Knott-Craig CJ, Ward KE, McCue C, Lane MM. Pulmonary autograft in children: realized growth potential. Ann Thorac Surg 1994;57:1387–94.[Abstract]
- Hasegawa J, Kitamura S, Taniguchi S, Kawata T, Niwaya K, Mizuguchi K, et al. Comparative rest and exercise hemodynamics of allograft and prosthetic valves in the aortic position. Ann Thorac Surg 1997;64:1753–6.[Abstract/Free Full Text]
- O’Brien MF, Harrocks S, Stafford EG, Gardner MA, Pohlner PG, Tesar PJ, et al. The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements. J Heart Valve Dis 2001;10:334–5.[Medline]
- Concha M, Pradas G, Juffe A, Caffarena JM, Montero A, Aranda PJ. Comprehensive experience with the Ross operation in Spain. Eur J Cardiothoracic Surg 2003;24:521–6.[Abstract/Free Full Text]
- Oury JH, Doty DB, Oswalt JD, Knapp JF, Mackey SK, Duran CM. Cardiopulmonary response to maximal exercise in young athletes following the Ross procedure. Ann Thorac Surg 1998;66(6 Suppl):S153–4.[Medline]
- Jaggers J, Harrison JK, Bashore TM, Davis RD, Glower DD, Ungerleider RM. The Ross procedure: shorter hospital stay, decreased morbidity, and cost effective. Ann Thorac Surg 1998;65:1553–8.[Abstract/Free Full Text]
- Bonow RO, Carabello B, de Leon AC Jr, Edmunds LH Jr, Fedderly BJ, Freed MD, et al. ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 1998;32:1486–588.[Free Full Text]
- Schmidtke C, Bechtel JF, Noetzold A, Sievers HH. Up to seven years of experience with the Ross procedure in patients > 60 years of age. J Am Coll Cardiol 2000;36:1173–7.[Abstract/Free Full Text]
- Bohm JO, Botha CA, Hemmer W, Starck C, Blumenstock G, Roser D, et al. Older patients fare better with the Ross operation. Ann Thorac Surg 2003;75:796–802.[Abstract/Free Full Text]
- Rubay JE, Sluysmans T. The pulmonary autograft: results and left ventricular function. Semin Thorac Cardiovasc Surg 1996;8:362–8.[Medline]
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INTRODUCTION
