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Ann Thorac Surg 1998;65:496-502
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

The Ross Operation in Children: 10-Year Experience

Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

Dr Elkins, Thoracic Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190.

Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background. The Ross operation, first performed in children in 1968, may be the ideal aortic valve replacement. Technical demands of the operation and two valves at risk have delayed acceptance. A review of our experience to assess midterm and long-term results with the Ross operation is presented.

Methods. The records of 150 consecutive patients, aged 7 days to 21 years (median age, 12 years, 75% less than 15 years) were reviewed. Follow-up was complete within the last 12 months (median, 2.8 years; range, 1 month to 10 years). Echocardiographic assessment was available on 116 (71%) within 1 year of closure and in 136 (91%) within 2 years.

Results. Survival was 97.3% at 8 years. Late autograft valve dysfunction required replacement in 2 and reoperation with restitution of autograft function in 6. Freedom from reoperation for autograft dysfunction is 90% ± 4% at 8 years. Freedom from reoperation for homograft obstruction is 94% ± 3% at 8 years. Pulmonary homograft dysfunction (gradient >40 mm Hg) was present in 4 additional patients. Freedom from reoperation on the homograft or a gradient of 40 mm Hg is 89% ± 4% at 8 years. All patients have a normal, active lifestyle, without anticoagulants for their aortic valve replacement.

Conclusions. The Ross operation is the preferred operative replacement in children requiring aortic valve replacement.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Pulmonary autograft replacement of the aortic valve (Ross operation) in a pediatric-age patient was originally performed by Ross in January 1968 [1]. Ross’ group suggest that "Should growth potential be realized, it might constitute the ideal biological valve for the left ventricular outflow in children" [1]. They identified the advantages of the autograft valve as central laminar flow; freedom from prosthetic valve sounds, hemolysis, and anticoagulation; and, as the autograft is autogenous living tissue, the possibility of indefinitely continuing function and growth with the patient.

Acceptance of these tenets by cardiologists and cardiac surgeons has been slow due to the technical demands of this aortic valve operation and the inherent need for reconstruction of the right ventricular outflow tract, thereby placing two valves at risk. During the past 10 years, increasing numbers of cardiac surgeons have used the Ross operation in children and young adults, demonstrating that the technical aspects of the operative procedure can be learned and the operative mortality is low [2] [3] [4]. Enlargement of the pulmonary autograft, as a valve replacement and as a root replacement, that is proportional to somatic growth of the patient has been demonstrated [5].

As additional surgeons have become experienced with the Ross operation, it has been identified as the operation of choice for children and young adults who require aortic valve operation. The indications for the Ross operation have expanded and the operative techniques have been modified. To assess the impact of some of these expanded indications and modifications of technique and to provide additional long-term follow-up of the Ross operation in children, especially those with a root replacement, we conducted the present review.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patients
One hundred fifty patients, 21 years of age or younger, underwent a Ross operation between August 1986 and November 1996. There were 112 male (75%) and 38 female (25%) patients with an age range of 7 days to 21 years (median age, 12 years). Ninety-five patients had a previous cardiac operation, 89 had a previous operation on their aortic valve, and 25 had an aortic balloon valvuloplasty. Aortic stenosis was the primary diagnosis in 40, aortic insufficiency in 29, and a combination of these hemodynamic lesions in 80. In 17 patients, aortic valve dysfunction was associated with subvalvar left ventricular outflow tract obstruction. Three of the 150 had endocarditis involving their aortic valve, and in 1 it was active at the time of his Ross operation. One patient had previously undergone a Manouguian aortic root enlargement and prosthetic aortic valve replacement and had development of mitral insufficiency; this patient had replacement of the prosthetic aortic valve with a Ross operation and a mitral valvuloplasty. Nine patients had a previous aortic valve replacement, 7 with a prosthetic valve and 2 with an aortic homograft. One patient had a bioprosthetic left ventricular–aorta conduit that was removed and his aortic stenosis/insufficiency and left ventricular outflow tract obstruction were corrected with a Ross operation and left ventricular myectomy.

All patients had preoperative transthoracic echocardiography, and for the past 6 years these findings have been confirmed with transesophageal echocardiography at the time of operation. In 56 patients a preoperative cardiac catheterization was accomplished when the patient’s preoperative diagnosis indicated the need for catheterization and angiography.

Surgical Technique
The surgical technique for pulmonary autograft replacement of the aortic valve has been described previously [6]. The early operative procedures included 20 in which the pulmonary autograft valve replacement was done as a scalloped subcoronary implant, the most common technique used by Ross’ group [7]. Thirty-two patients had their autograft valve inserted as an inclusion cylinder and 98 had a root replacement of their aortic root. The implantation technique was selected based on the age of the patient, size of the aortic annulus, dysplasia of the aortic annulus, and presence of subvalvar obstruction or dysplasia. More recently the root replacement has become the most commonly used operative technique. The effect of age on implantation technique is shown in Fig 1.

View larger version (19K): [in this window] [in a new window]   Age range of patients with pulmonary autograft replacement of their aortic valve. Root replacements and intraaortic implants for each age group are displayed.

Homograft reconstruction of the right ventricular outflow tract was accomplished with a cryopreserved pulmonary homograft in 149 patients and with a cryopreserved aortic homograft in 1. In most patients, including the very young, it was possible to use an adult-sized homograft (Fig 2).

View larger version (13K): [in this window] [in a new window]   Pulmonary homograft size in millimeters plotted against patient body surface area. Most pulmonary homografts are adult size (>20 mm) even in small patients.

Valve-related mortality and morbidity were categorized according to the guidelines of Edmunds and associates [11].

Statistical Analysis
All analyses were performed using SAS System software, version 6.10 (SAS Institute, Cary, NC). Between-group differences of continuous variables were analyzed using analysis of variance methods, and ² or Fisher’s exact methods were used to test differences between proportions. Patient survival analysis and actuarial estimates of freedom from postoperative events were accomplished using Kaplan-Meier methods. Survival curves are displayed to the point in time where the standard error of the estimate exceeds 10% unless otherwise noted. Differences between survival distributions were assessed by log-rank and Wilcoxon testing, and p values less than 0.05 were considered significant for all tests.

Cox proportional hazards multivariable regression was used for investigating variables associated with (1) development of 2+ aortic insufficiency or reoperation on the autograft valve and (2) development of a 40 mm Hg or greater gradient or reoperation on the homograft valve. A forward stepwise selection method was used to add variables to the model, requiring significance at p less than 0.05 for entry and retention in the model. Variables considered for the autograft valve outcomes model were age, sex, diagnosis of aortic stenosis, previous aortic valve operation, year of operation, thoracic aortic aneurysm, type 1 VSD, history of bacterial endocarditis, and insertion technique (root replacement, inclusion cylinder, or scalloped subcoronary). Variables analyzed for association with homograft outcomes were age, sex, previous cardiac operation, year of operation, history of bacterial endocarditis, and size of homograft.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Mortality and Morbidity
There were four operative deaths, for an operative mortality of 2.7%. All of these deaths occurred in the root replacement patients, for an operative mortality of 4.1% for this operative technique. Two of the deaths were associated with the left coronary anastomosis to the autograft root. There have been no late deaths, and the actuarial survival at 8 years is 97.3% ± 1.3%.

Early postoperative morbidity occurred in 5 patients. Two required reexploration for bleeding: 1 from a homograft suture line and 1 from an autograft root replacement suture line. Three patients required permanent pacemakers for complete heart block: 1 with a unicusp aortic valve and severe aortic annulus dysplasia, 1 requiring aortic annulus reduction, and 1 requiring replacement of a prosthetic aortic valve.

Eight patients have required reoperation of the autograft valve for insufficiency. Progressive autograft insufficiency developed in 1 patient, and by 2 months after his Ross operation and replacement of an 8-cm ascending aortic aneurysm, increasing aortic annulus dilatation had developed. At reoperation, the aortic annulus was reduced in size from 26 mm to 20 mm with restoration of normal autograft function. A second patient required early autograft reoperation (7 months), which required replacement of the scalloped subcoronary implant. This was the second patient in this series, and this failure was thought to be due to the early learning curve. Six patients required reoperation for autograft insufficiency more than 1 year after their Ross operation. One required replacement as a leaflet had prolapsed and become adherent to a VSD patch used to close a subarterial VSD. The remaining 5 have had successful treatment of their autograft valve insufficiency, with annular reduction in 5 and reduction and fixation of the sinotubular dimension in 2 [9]. Of the 146 survivors, 144 (98.6%) continue to retain the benefits of their autograft valve. One patient required reoperation for recurrence of subvalvar stenosis treated by resection and left ventricular myectomy. Actuarial freedom from reoperation for autograft insufficiency or recurrent left ventricular obstruction was 90% ± 4% at 8 years (Fig 3).

View larger version (22K): [in this window] [in a new window]   Actuarial freedom from reoperation or peak gradient greater than 40 mm Hg of homograft used to reconstruct right ventricular outflow tract in 146 children. (SVR = subvalvar resection.)

View larger version (16K): [in this window] [in a new window]   Actuarial freedom from reoperation on pulmonary autograft valve or left ventricular outflow tract in 146 children.

Valve-Related Complications
Reoperation on the autograft valve, development of increasing autograft insufficiency, development of pulmonary homograft obstruction, or reoperation on the pulmonary homograft have been the only valve-related complications in the 146 surviving patients. The actuarial freedom from all valve-related complications is 72% ± 6% at 8 years.

Multivariate Analysis
The results of Cox proportional hazards regression are shown in Table 1Table 2. Table 1 shows the analysis for the end point defined as the need for reoperation on the autograft valve or development of 2+ autograft insufficiency on two or more consecutive echocardiographic evaluations. Univariate (ie, unadjusted for other factors) analysis indicated that previous aortic valve operation, preoperative diagnosis of aortic stenosis, and later year of operation decreased the likelihood of reoperation for autograft insufficiency or the development of 2+ aortic insufficiency. The presence of an ascending aortic aneurysm or type 1 VSD increased the risk of these autograft complications. Multivariate analysis identified previous aortic valve operation and later year of operation as protective and ascending aortic aneurysm as a risk for autograft complications.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
During the past 10 years the use of the autogenous pulmonary valve as a replacement for the aortic valve has increased in children and young adults. As its use has increased, the aortic valve pathology and associated cardiac disease that is being treated with the Ross operation has increased in complexity. Patients with active bacterial endocarditis [12]; patients with multilevel left ventricular outflow tract obstruction requiring aortoventriculoplasty [13] [14]; patients with a bicuspid aortic valve, aortic insufficiency, and dilatation of the aortic annulus [8]; and patients with ascending aortic aneurysms associated with their aortic valve disease [8] are receiving a pulmonary autograft root replacement in conjunction with modifications and additions to the Ross operation to correct these additional pathologic entities. Follow-up data on the results of these modifications or additions to the Ross operation are limited. The first pulmonary autograft root replacement at our institution was performed in March 1987 [15], and the first such operation in a child was done in May 1987. Both of these operations required an aortoventriculoplasty for relief of multilevel left ventricular outflow tract obstruction. As listed in the Surgical Technique section, a significant number of the patients required operative modifications of the Ross operation, and by multivariate analysis the operative modification that was associated with an increased risk for reoperation on the autograft valve or the development of 2+ autograft insufficiency is the presence of an ascending aortic aneurysm that required replacement (1 reoperation in 4 patients). In the patient who required reoperation, central autograft insufficiency developed, which was associated with annular dilatation in the early postoperative period. Operative reduction of the aortic annulus restored normal autograft function.

One patient-related factor that also requires modification of the Ross operation is the presence of a subarterial infundibular ventricular septal defect. This defect was associated with an increased risk of early failure by univariate analysis (p < 0.01). Three of 7 patients with subarterial VSD required reoperation or had development of 2+ autograft insufficiency. Those patients with a subarterial VSD who have had stable autograft function have had fixation of the autograft annulus at the time of autograft root replacement or have had closure of the VSD with the anterior wall of the right ventricle as described for closure of the ventriculotomy when performing an aortoventriculoplasty [14].

Previous multivariate analysis for autograft valve failure of all patients having a Ross operation at our institutions demonstrated that a previous aortic valve operation was protective [9]. Further analysis of those data demonstrated that this was due to the preoperative diagnosis of aortic stenosis and that patients with a bicuspid aortic valve and aortic insufficiency as their preoperative diagnosis were more likely to have autograft valve failure. This was again confirmed in this subset of patients, ie, 21 years of age or less. The benefit of later year of operation is thought to be related to the "learning curve," the more widespread use of the autograft root replacement, and adoption of techniques to reduce the size of the aortic annulus and "fix" the size of the aortic annulus where appropriate. Long-term data on some of these modifications or additions to the Ross operation are not available, but present results are very encouraging.

Pulmonary autograft root replacement was used in 95 of the patients (65%), and the length of follow-up on the use of this technique now extends to 10 years. The initiation of this technique for the Ross operation is similar in our experience [16] and the experience reported by Gerosa and associates [17]. In a multivariate analysis previously reported, this technique was associated with a decreased frequency of reoperation on the autograft valve or the development of 2+ autograft valve insufficiency [9]. Although in the children this multivariate association was not statistically significant, it is encouraging that for the available period of follow-up outcome appears to be at least equal to that reported for the scalloped subcoronary technique. Long-term data (>20 years) are available for the scalloped subcoronary technique, with a reported freedom from reoperation of 85% at 20 years [7].

The present series is of particular interest as 99% of the surviving patients continue to maintain the benefits as described by Ross’ group of their pulmonary autograft valve. The incidence of failure of the pulmonary homograft valve (94% at 8 years) has been gratifyingly low, and reoperation has not been difficult. Using a very rigid definition of valve-related complications, the freedom from all valve-related complications is 77% at 8 years. There are no comparable series of patients with prosthetic aortic valves reported. Limited experiences with the newer prosthetic aortic valves in children have been reported with a low operative mortality and an 8- to 10-year survival of 80% to 100% in three different series [18] [19] [20]. In young children with a small annulus, annular enlargement with a Konno-Rastan, Manouguian, or Nicks procedure to allow placement of an adult-sized valve has been recommended [19]. Anticoagulation has been used in most patients; aspirin and dipyridamole are suggested as adequate in patients who are in sinus rhythm, but some authors recommend the use of warfarin anticoagulation [19]. Continued follow-up of patients with prosthetic aortic valves, aortic annular enlargement, and anticoagulant therapy will identify whether they have a reduced incidence of valve-related complications and late death as compared with the results that appear to be obtainable with the Ross operation.

The Ross operation in children appears to have an operative risk that is low and to provide a lifestyle that is unencumbered by anticoagulants. The valve-related complications are not life-threatening, and the most serious risk, that of reoperation, appears to be small. Long-term satisfactory autograft valve function can be achieved. We continue to recommend the Ross operation as the procedure of choice in children who require aortic valve replacement.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Gerosa G, McKay R, Ross DN Replacement of the aortic valve or root with a pulmonary autograft in children. Ann Thorac Surg 1991;51:424-429.[Abstract]
2. Elkins RC, Knott-Craig CJ, Randolph JD, et al. Medium-term follow-up of pulmonary autograft replacement of aortic valves in children. Eur J Cardiothorac Surg 1994;8:379-383.[Abstract]
3. Kouchoukos NT, Davila-Roman VG, Spray TL, Murphy SF, Perrillo JB Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic valve disease. N Engl J Med 1994;330:1-6.[Abstract/Free Full Text]
4. Schoof PH, Cromme-Dijkhuis AH, Bogers AJJC, et al. Aortic root replacement with pulmonary autograft in children. J Thorac Cardiovasc Surg 1994;107:367-373.[Abstract/Free Full Text]
5. Elkins RC, Knott-Craig CJ, Ward KE, McCue C, Lane MM Pulmonary autograft in children: realized growth potential. Ann Thorac Surg 1994;57:1387-1394.[Abstract]
6. Elkins RC, Santangelo K, Stelzer P, Randolph JD, Knott-Craig CJ Pulmonary autograft replacement of the aortic valve: an evolution of technique. J Card Surg 1992;7:108-116.[Medline]
7. Ross D, Jackson M, Davies J Pulmonary autograft aortic valve replacement: long-term results. J Card Surg 1991;6:529-533.[Medline]
8. Elkins RC, Knott-Craig CJ, Howell CE Pulmonary autografts in patients with aortic annulus dysplasia. Ann Thorac Surg 1996;61:1141-1145.[Abstract/Free Full Text]
9. Elkins RC, Lane MM, McCue C Pulmonary autograft reoperation: incidence and management. Ann Thorac Surg 1996;62:450-455.[Abstract/Free Full Text]
10. Elkins RC The Ross operation: applications to children. Semin Thorac Cardiovasc Surg 1996;8:345-349.[Medline]
11. Edmunds LH, Jr, Clark RE, Cohn LH, Grunkemeier GL, Miller DC, Weisel RD Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ann Thorac Surg 1996;62:932-935.[Abstract/Free Full Text]
12. Oswalt JD, Dewan SJ Aortic infective endocarditis managed by the Ross procedure. J Heart Valve Dis 1993;2:380-384.[Medline]
13. Daenen W, Gewillig M Extended aortic root replacement with pulmonary autografts. Eur J Cardiothorac Surg 1993;7:42-46.[Abstract]
14. Reddy VM, Rajasinghe HA, Teitel DF, Haas GS, Hanley FL Aortoventriculoplasty with the pulmonary autograft: the "Ross-Konno" procedure. J Thorac Cardiovasc Surg 1996;111:158-167.[Abstract/Free Full Text]
15. Stelzer P, Elkins RC Homograft valves and conduits: applications in cardiac surgery. Curr Probl Surg 1989;26:381-452.[Medline]
16. Stelzer P, Jones DJ, Elkins RC Aortic root replacement with pulmonary autograft. Circulation 1989;80(Suppl 3):209-213.
17. Gerosa G, McKay R, Davies J, Ross DN Comparison of the aortic homograft and the pulmonary autograft for aortic valve or root replacement in children. J Thorac Cardiovasc Surg 1991;102:51-61.[Abstract]
18. Moodie DS, Hanhan U, Sterba R, Murphy DJ, Jr, Rosenkranz ER, Kovacs AM Aortic valve replacement in young patients: long-term follow-up. Cleve Clin J Med 1992;59:473-478.[Medline]
19. Harada Y, Imai Y, Kurosawa H, Ishihara K, Kawada M, Fukuchi S Ten-year follow-up after valve replacement with the St. Jude Medical prosthesis in children. J Thorac Cardiovasc Surg 1990;100:175-180.[Abstract]
20. El Makhlouf A, Friedli B, Oberhansli I, Rouge JC, Faidutti B Prosthetic heart valve replacement in children. J Thorac Cardiovasc Surg 1987;93:80-85.[Abstract]

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				P. T. Roughneen, S. Y. DeLeon, B. W. Eidem, N. J. Thomas, F. Cetta, D. A. Vitullo, K. E. Magliato, T. E. Berry, and M. Bakhos Semilunar valve switch procedure: autotransplantation of the native aortic valve to the pulmonary position in the ross procedure Ann. Thorac. Surg., March 1, 1999; 67(3): 745 - 750. [Abstract] [Full Text] [PDF]

				K. Niwaya, C. J. Knott-Craig, M. M. Lane, K. Chandrasekaren, E. D. Overholt, and R. C. Elkins CRYOPRESERVED HOMOGRAFT VALVES IN THE PULMONARY POSITION: RISK ANALYSIS FOR INTERMEDIATE-TERM FAILURE J. Thorac. Cardiovasc. Surg., January 1, 1999; 117(1): 141 - 147. [Abstract] [Full Text] [PDF]

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