SAN DIEGO – Reoperations after the Ross procedure remain rare, at 11%, results from a long-term single-center study showed.
The main reason for reoperation appears to be autograft dilatation, Dr. Francis Juthier reported at the annual meeting of the Society of Thoracic Surgeons.
Dr. Francis Juthier
"A major drawback of the Ross operation is a progressive dilatation of the neo–sinuses of Valsalva in patients who undergo root replacement," said Dr. Juthier, a cardiovascular surgeon at the Centre Hospitalier Régional Universitaire de Lille (France). "Cryopreserved pulmonary homograft is also subject to structural failure."
In an effort to better understand the need for reoperation after the Ross procedure, Dr. Juthier and his associates studied 336 adult and pediatric patients who underwent the procedure at the hospital between March 1992 and February 2010. The mean age of patients was 29 years, and the mean follow-up period was 6.2 years.
Of the 336 patients, 38 (11%) required reoperation. The chief cause of reoperation was autograft dilatation in 23 cases, which occurred an average of 9.6 years after the original Ross procedure. All of these patients initially had a complete aortic root replacement. The subsequent procedures included a mechanical Bentall intervention in 19 cases, valve-sparing surgery in 3 cases, and insertion of a stentless bioprosthesis in 1 case.
The second most common cause for reoperation was autograft regurgitation, which occurred in nine patients at an average of 2.6 years after the Ross procedure. All of these patients underwent mechanical aortic valve replacement.
The third most common cause for reoperation was infective endocarditis, which occurred in three cases at an average of 3.8 years after the Ross procedure. The subsequent procedures included aortic and pulmonary valve replacement.
Dr. Juthier also reported that two patients required reoperation because of a proximal autograft anastomosis dehiscence (pericardial patch repair), and one required removal of a left intra-atrial mass.
No perioperative deaths occurred, and all-cause early mortality was 3.3%. Overall survival was 93% at 10 and 15 years, whereas freedom from reoperation or reintervention was 87% at 10 years and 77% at 15 years.
Freedom from autograft explantation was 89% at 10 years and 83% at 5 years, whereas freedom from homograft explantation was 98% at 10 years and 93% at 15 years.
Univariate predictors for reoperation resulting from autograft dilatation were autograft regurgitation (hazard ratio, 3.23), aortic annulus diameter of greater than 1.35 cm/m2 (HR, 3.83), and autograft diameter (HR, 1.2 per mm).
The current policy at the university’s hospital, Dr. Juthier said, is to perform a modified Ross procedure with the autograft included in a Valsalva Gelweave Dacron tube in adult patients who have an aortic annulus that measures 20 mm or greater in diameter.
Dr. Juthier said that he had no relevant financial conflicts to disclose.