probably required reading for anyone considering the Ross
full text here:
http://circ.ahajournals.org/content/122/12/1139.full
Reoperations After the Ross Procedure
- Tirone E. David, MD
{Pellicle: some emphasis added by me in the following}
There is no perfect heart valve substitute, and the Ross procedure to treat aortic valve disease is no exception. In this issue of Circulation, Stulak and associates from the Mayo Clinic give a detailed account of the outcomes of reoperations on 56 patients who had the Ross procedure.1 The authors concluded that “a broad spectrum of complex reoperations may be required after the Ross procedure,” and that “patients and family members considering the procedure should be informed of the potential for associated morbidity should reoperation be necessary.” The reality, however, is that the Ross procedure is a complex operation, and one should not be surprised that reoperations are more complicated. The authors emphasized that 144 procedures were needed in those 56 patients. However, considering that the Ross procedure involves two heart valves and possibly the neoaortic root and the coronary arteries if the technique of aortic root replacement was used at the initial operation, one should not be surprised about the number of procedures at reoperations. Nevertheless, among those 144 procedures, the authors included enlargement of the pulmonary (28 patients) and aortic annulus (4 four patients) as additional operations when they are really part of valve replacement. Other procedures, such as replacement of the ascending aorta for aneurysm, mitral valve surgery, and atrial septal defect (19 patients total) have more to do with the patients' cardiovascular pathology than the fact that they had a previous Ross procedure. In spite of these complex and extensive reoperative procedures, only one patient died–a remarkably low operative mortality of only 1.8%. However, it is worrisome that within a median follow-up of only 8 months there were 4 additional deaths. Thus, one can estimate 1-year survival of approximately 90%, which is low for such a young population, and is probably the reason this experience raised concerns among the investigators. Based on this study, it was not possible to have an appreciation for the magnitude of the problem of reoperations after the Ross procedure, because the authors did not have the total number of patients at risk. Forty-three patients had the initial operation elsewhere and 13 at the Mayo Clinic. Those 13 patients were among a total of 39 who had the Ross procedure at the Mayo Clinic. Thus, approximately 1 in 3 patients operated on at the Mayo Clinic required a reoperation. Although this is a small sample size, the high proportion of reoperations may also have raised concerns among the investigators.
We recently reported the late outcomes of the Ross procedure in a cohort of 212 patients (mean age of 34 years in a range of 16 to 63 years) who were prospectively followed for a mean of 10 years and had assessment of valve function by echocardiography.2 An important finding in that study was that patients' survival at 15 years was similar to that of the general population, when matched for sex and age. Twenty patients required reoperations: 13 in the pulmonary autograft, 3 in the pulmonary valve, and 4 others. No patient died at reoperation. At 15 years, the freedom from reoperation on the pulmonary autograft was 92%, the freedom from reoperation in the pulmonary valve was 97%, and the freedom from any cardiac reoperation was 85%. Preoperative aortic insufficiency was the only independent predictor of reoperation on the pulmonary autograft. Valve function was monitored by periodical echocardiography, and at 15 years, the freedom from moderate or severe aortic insufficiency was 89.7% and the freedom from greater than mild aortic insufficiency was 63.2%. Because of the relatively small number of adverse events, we used the development of greater than mild aortic insufficiency to identify predictors of pulmonary autograft dysfunction. Male sex, aortic/pulmonary annular mismatch, aortic annulus =27 mm, and preoperative aortic insufficiency were associated with greater risk of late aortic insufficiency by log-rank analysis. Dysfunction of the pulmonary homograft was defined by the presence of moderate or severe pulmonary insufficiency and/or a peak systolic gradient =40 mm Hg, The freedom from dysfunction of the pulmonary homograft at 15 years was 70.8%.
There are only few publications on the Ross procedure that provide outcomes beyond the first decade, and the results have not been always as gratifying as in our series.3–4 Kieverik et al5 reported their experience with 146 patients with a mean follow-up of 8.7 years, and the freedom from reoperation on the autograft at 13 years was 69% and significantly better in patients <16 years of age than in older patients (92% versus 56.7%; P<0.02). In a report by Elkins and associates,6 who probably had the largest experience with the Ross procedure in North America, the freedom from pulmonary autograft failure was 74% at 16 years and was similar for children and young adults. As in our series, Elkins et al6 found that preoperative aortic insufficiency and male sex were independent predictors of pulmonary autograft failure.
...
A common criticism of the Ross procedure is that it creates double valve disease in patients who have only aortic valve disease. The pulmonary valve is usually replaced with a pulmonary valve homograft. The fate of the pulmonary homograft after the Ross procedure varies among reports, depending on how dysfunction is defined, but it is seldom a life-threatening problem. Failure of the pulmonary homograft is more common in children than in adults.4,10 However, the pulmonary homograft in children seems to be more durable after the Ross procedure than after other types of right ventricular outflow tract reconstruction for congenital heart diseases.11 With the advent of catheter-based pulmonary valve implantation, the problem of pulmonary homograft failure is being further mitigated.
...
We have to keep this problem in perspective, because aortic valve replacement is a palliative operation. There are a multitude of operations developed to treat aortic valve disease. Valve repair is an excellent palliation in certain patients with incompetent bicuspid aortic valve or aortic root aneurysm. However, in patients with aortic stenosis or aortic insufficiency due to advanced disease of the cusps, aortic valve replacement with a tissue or mechanical valve is the only effective treatment. Aortic valve homograft and bioprosthetic aortic valves have limited durability in children and young adults. Mechanical valves are more durable than biological and bioprosthetic valves, but they are far from perfect, because in addition to a constant risk of anticoagulation-related hemorrhage, thromboembolic complications, and prosthetic valve endocarditis, an ever-increasing number of patients are now being referred for reoperation because of prosthetic valve stenosis due to pannus two or more decades after aortic valve replacement. And these reoperations may also be very complicated because the pannus may become calcified, and reconstruction of the left ventricular outflow tract may be necessary before a new valve can be implanted.
.... The Ross procedure remains an important part of the surgical armamentarium to treat aortic valve disease in children and young adults, but we need more information on late outcomes of this operation.
As for myself I've had 3 "
palliation surgeries":
- valvotomy at 10yo
- homograft at 28yo
- mechanical and ascending aortic artery graft (bentall)
At 60 (time of writing) I'm happy to say I'm pretty normal and live pretty normally. I hope all other valvers get at least as good.
Best Wishes
.