Nelamangala The Annals of Thoracic Surgery
Volume 111, Issue 1, January 2021, Pages 159-167
buy brand provigil online Thierry Bové MD, PhD, Nicolas Bradt MSc, Thomas Martens MD, Daniel De Wolf MD, PhD, Katrien François MD, PhD, Geoffroy de Beco MD, Thierry Sluysmans MD, PhD, Jean Rubay MD, PhD, Alain Poncelet MD, PhD
neurontin online Progressive autograft dilation and need for later reoperation remain major concerns of the Ross procedure. The study investigates the clinical outcome after the Ross operation, including a longitudinal analysis of autograft dimensions over 25 years.
Roeselare From November 1991 to April 2019, 137 patients underwent a Ross procedure at the University Hospitals of UCL (Université catholique de Louvain)-Brussels and Ghent. Inclusion criteria were less than or equal to 18 years of age and pulmonary autograft implantation by root replacement. Outcome focused on survival, reoperation rate, and autograft size evolution through linear mixed-model analysis.
A Ross or Ross-Konno operation was performed in 110 (80%) and 27 (20%) patients at a median age of 10.4 (interquartile range [IQR], 4.7-14.3) years and 0.5 (IQR, 0.04-5.2) years, respectively. Overall 10-year and 20-year survival was 87% ± 3% and 85% ± 3%, respectively, but was 93% ± 3% for isolated Ross patients. Right ventricular outflow tract–conduit exchange was required in 20.3%, whereas autograft-related reoperation was performed in 14 (10.7%) patients at a median interval of 14 (IQR, 9-16) years, for aortic regurgitation (n = 2) and autograft dilation (n = 12). Autograft z-values increased significantly at the sinus and sinotubular junction (STJ) compared with the annulus (annulus = 0.05 ± 0.38/y, sinus = 0.14 ± 0.25/y, STJ = 0.17 ± 0.34/y; P = .015). The z-value slope for autograft dimensions was significantly steeper for Ross-Konno vs Ross patients (annulus: P = .029; sinus: P < .001; STJ: P = .012), and for children having aortic arch repair (annulus: P = .113, sinus: P = .038; STJ: P = .029).
The Ross operation offers children requiring aortic valve replacement an excellent survival perspective, with an acceptable risk of autograft reoperation within the first 25 years. Contrary to the autograft annulus, dilation of the sinus and STJ size is of concern. Closer surveillance of autograft dimensions might be required in patients who underwent a Ross-Konno procedure or aortic arch reconstruction.
Thierry Bove and colleagues have reported in this study on the long-term results of the Ross and Ross Konno operation. The highlight of this paper is that it has demonstrated a constant increase of autograft dimensions particularly at the level of the sinus and sinotubular junction which was pronounced in children after previous Ross-Konno surgery and aortic arch reconstruction. This study further reiterates the fact that alternate strategies need to be adopted to mitigate the autograft dilation which is worrisome in the long-term freedom from re-operation. Neonates and infants with aortic valve disease can be managed by a surgical valvotomy to delay the Ross operation1. Buratto and colleagues2 found that freedom from autograft failure was better when the Ross operation was performed as a secondary procedure following aortic valve repair as post-operative adhesions may limit dilation of the autograft. Hraska and colleagues3 suggest that the Ross-Konno procedure be reserved for infants with small left heat structures who will benefit from LVOT enlargement. In children and young adult the autograft dilation can be mitigated by the so-called reinforced Ross operation4.
In conclusion, autograft dilation is a concern in the long-term freedom from reoperation for the Ross operation and this can be mitigated by strategies such as the 2-stage approach or the reinforced Ross operation.