Ann Thorac Surg 2005;80:2277
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Craig R. Smith, MD
Department of Cardiothoracic Surgery, Columbia Presbyterian Medical Center, Milstein Hospital Bldg 7-435, 177 Fort Washington Ave, New York, NY 10032
(Email: crs2{at}columbia.edu).
Luciani and coauthors [1] have presented a large and thoughtfully analyzed experience with the Ross procedure. In their hands, the Ross procedure continues to be "... the preferred surgical option in the child and young adult due to unsurpassed survival and quality of life." This is a strong statement that must be examined carefully. It is true that operative mortality (1%) and 10-year survival (98%) are unquestionably excellent and difficult to surpass. Ten-year freedom from autograft dilatation (43%), regurgitation (75%), and reoperation (72%) is a different story. These findings add to the steadily growing evidence that the Ross procedure is far from fulfilling the promise of a near-permanent solution that propelled its startling popularity in the 1990s.
Should the Ross procedure be "the preferred surgical option" in children and young adults? This position is easy to defend in growing children; the younger the patient, the less attractive the alternatives. However, this series has an average age of 29 years (range 6–49 years). These are not children, but young and middle-aged adults, for which valve replacements with equal or greater durability are undeniably available. With this in mind, a truth-in-advertising issue arises when the authors state that the Ross procedure is reserved for patients with aortic valve disease "not amenable to other reparative procedures." It may be more balanced to state that alternatives to the Ross procedure, as presented to the patients by their caregivers, were judged to be less advantageous. Knowing the results of their series, one wonders which advantages of the Ross procedure receive emphasis: 72% freedom from reoperation at 10 years is surely not one of them.
I do not mean to imply that the Ross procedure is not a good operation in experienced hands. Luciani and coauthors are to be commended for performing a challenging operation extremely well and for conscientiously presenting their long-term results. I would be the first to applaud the Ross procedure as one among other alternatives to the quotidian nightmare that is warfarin anticoagulation, if only for a decade or so. One only needs to look at the current vogue for hyper-aggressive treatment of atrial fibrillation—a guideline-driven warfarin pandemic—to appreciate alternatives to a mechanical valve.
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- Luciani GB, Favaro A, Casali G, Santini F, Mazzucco A. Ross operation in the younga ten-year experience. Ann Thorac Surg 2005;80:2271-2277.[Abstract/Free Full Text]
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