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Ann Thorac Surg 2007;83:1781-1789
© 2007 The Society of Thoracic Surgeons
Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
Accepted for publication December 27, 2006.
* Address correspondence to Dr Brown, Section of Cardiothoracic Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 215, Indianapolis, IN 46202-5123 (Email: jobrown{at}iupui.edu).
Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
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Abstract |
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Methods: Between 1993 and 2005, 170 patients (mean age, 24.9 ± 15.5 years; range, 1 month to 61 years) underwent Ross aortic valve replacement: 48% were younger than 19 years old. Eighty-seven additional procedures were performed in 58 patients (34%) at the time of the Ross procedure. End points of the study were freedom from autograft dilation (z value more than +2.0), autograft dysfunction, autograft reoperation, and autograft replacement.
Results: There were 2 early and 1 late deaths during a mean follow-up of 5.1 ± 3.0 years (range, 1 month to 12 years). Actuarial survival at 10 years was 98%. Autograft dilation was identified in 31 patients (19%). Regurgitation (>2+) was identified in 12 patients (7%); all 12 had autograft dilation. At 10 years, freedom from autograft dilation was 82%, freedom from autograft dysfunction was 92%, freedom from reoperation on autograft was 92%, and freedom from autograft replacement was 96%. Cox proportional hazard analysis identified preoperative aortic annulus dilation (z value more than +2.0; p = 0.004), younger age (p = 0.05), time of surgery (before 2001; p = 0.002), and male sex (p = 0.01) as predictive of autograft dilation, whereas preoperative ascending aorta diameter (p = 0.01), male sex (p = 0.03), and postoperative systemic hypertension (p = 0.05) were predictive of autograft dysfunction.
Conclusions: Significant autograft dilation is not common after the Ross procedure. Significant autograft dysfunction affects a minority of patients, but it is more prevalent in those with autograft dilation.
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Introduction |
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The durability and the lack of need for postoperative anticoagulation are advantages available to adults and children who require AVR [2–7]. The potential for autograft growth and the adaptability of the autograft to treat multilevel left ventricular (LV) outflow tract obstruction are particularly important to children who require AVR [5, 7, 8–13]. Pulmonary autograft growth and dilation, however, cannot always be easily distinguished from one another, and several reports indicate that both dilation and growth occur in the growing subjects. The concern about pathologic autograft dilation leading to regurgitation and the need for reoperation are the disadvantages of the Ross AVR [6–8, 10–12, 14–16].
The aim of this retrospective study is to define the prevalence, risk factors, and consequences of late autograft dilation after Ross AVR at our institution.
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Material and Methods |
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Surgical Technique
Standard techniques of cardiopulmonary bypass were used, with bicaval cannulation, moderate hypothermia, and antegrade and retrograde cold-blood potassium cardioplegia. A standard full-root technique was used for all Ross patients, as previously described [19]. When a Ross-Konno procedure (n = 16) was performed, the autograft was harvested with a 1- to 1.5-cm extension of attached right ventricular infundibular free wall muscle for use in patching the septoplasty incision. The right ventricular outflow tract was then reconstructed with an appropriately oversized (6- to 10-mm larger than the autograft) cryopreserved pulmonary homograft (n = 142) or a decellularized pulmonary homograft (SynerGraft, n = 23; CryoLife, Inc, Kennesaw, GA), or a glutaraldehyde-preserved bovine jugular vein with integral venous valve (Contegra, Medtronic, Inc, Minneapolis, MN; n = 5). The patients were separated from bypass in the usual manner, and intraoperative transesophageal echocardiography was performed. Forty-one patients had preoperative aortic annular dilation and underwent reduction and fixation of the aortic annulus with a polytetrafluoroethylene (Teflon) strip (n = 30), ascending aorta replacement with synthetic graft (n = 6), and ascending aorta reduction with subsequent replacement with a synthetic graft (n = 5). The aortic annulus was reduced from 33.3 ± 7.0 to 25.0 ± 2.5 mm (p = 0.005). Autograft annulus sizes used in patients with Ross procedure are shown in Figure 1.
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Actuarial survival, freedom from autograft dilation, freedom from autograft reoperation, and freedom from autograft replacement were analyzed for the following potential risk factors: age, age younger than 1 month, weight, sex, time of surgery (before and after 2001), preoperative ventilatory support, endocardial fibroelastosis, presence of hypoplastic left ventricle, presence of mitral anomaly, presence of other associated cardiovascular anomalies, presence of multilevel stenosis, LV ejection fraction, peak transaortic valve gradient, preoperative and follow-up z value more than +2.0 at the aortic annulus and sinus of Valsalva level, postoperative systemic hypertension, postoperative extracorporeal membrane oxygenation support, preoperative aortic stenosis and aortic regurgitation, and postoperative autograft stenosis and regurgitation. The analyses were performed with Cox proportional hazards regression. A forward stepwise selection method was used to add variables to the model, requiring significance at p less than 0.10 for entry and p less than 0.05 for retention.
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Results |
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Follow-up was available in all the patients, but only 80% had late postoperative echocardiograms. The mean follow-up time was 5.1 ± 3.0 years (range, 1 month to 12 years). One hundred forty-six patients (146 of 167, 87%) were in New York Heart Association functional class I and 21 (21 of 167, 13%) were in class II. All surviving patients are doing well and have not required medications for congestive cardiac problems after the third postoperative month.
Intraoperative Echocardiography
A transesophageal echocardiogram was routinely performed in the operating room after Ross AVR. No or trivial neoaortic insufficiency was observed in 148 patients (87%), and 22 (13%) had mild aortic insufficiency (AI). No patient had significant LV outflow tract obstruction. The valved conduit used to reconstruct the right ventricular outflow tract was competent in 150 patients (88%) and showed mild regurgitation in 20 (12%). No patient had important flow acceleration (obstruction) across the right ventricular outflow tract reconstruction.
Pulmonary Autograft Dilation
A total of 131 patients (80%) had early and late measurements of the diameter of the pulmonary autograft annulus. The diameter of the pulmonary autograft annulus decreased in 56 patients and increased in 75 patients. Overall at last follow-up, the diameter of the pulmonary autograft annulus increased from 22.9 ± 3.7 mm to 25.3 ± 4.9 mm (p < 0.001).
Maximal autograft diameters at the level of the sinus of Valsalva was specifically mentioned in 118 (90%) of the 131 patients having both early and late echocardiograms. These measurements were indexed to body surface area (meters squared) and compared with normal values for aortic root diameters in infants, children, and young adults (Fig 2). At last follow-up 90% of autograft diameters indexed to body surface area were greater than the 90th percentile of normal aortic diameters. The mean diameter was 39.3 ± 8.1 mm (range, 21 to 75 mm). There was no significant difference for risk of developing autograft dilation between patients who presented with bicuspid or tricuspid valve (p = 0.44). The mean z value was 0.6 ± 0.9 (range, –0.01 to +2.6). Thirty-one patients (19%; 17 pediatric and 14 adults) exhibited moderate aortic root dilation (z value more than +2.0; range, 2.1 ± 0.8). Aortic root dilation has occurred during 6.2 ± 2.7 years (range, 2 to 10 years). Most of the dilations occurred during the first 3 years after undergoing Ross AVR (Fig 3). The actuarial freedom from autograft dilation (z value more than +2.0) is 94% at 1 year, 86% at 5 years, and 82% at 10 years. Cox proportional hazard analysis identified preoperative aortic annulus dilation (z value more than +2.0; p = 0.004), younger age (p = 0.05), time of surgery (before 2001; p = 0.002), and male sex (p = 0.01) as predictive of autograft dilation.
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Pulmonary Autograft Reoperation
During follow-up, reoperation on the pulmonary autograft was performed on 14 patients (9%), 1 of whom had two procedures (Table 4). All reoperations for autograft insufficiency or ascending aortic dilation were carried out at a median interval of 6 years (mean, 5.9 ± 2.2 years; range, 2 to 10 years). Autograft annuloplasty with resection of ascending aortic aneurysm and ascending aorta replacement with synthetic graft was performed in 6 patients (4%), and aortic root replacement with a mechanical prosthetic composite graft was done in 7 patients (4%). One patient had repair of an LV pseudoaneurysm below the Ross valve. All patients survived reoperation. Therefore, among the 14 reoperated patients, 7 have prosthetic cardiac valves and 7 have their native autograft valve. Actuarial freedom from replacement of the pulmonary autograft is 98% at 5 years, and 96% at 10 years (Fig 4). Actuarial freedom from reoperation on pulmonary autograft is 98%, 98%, and 92% at 1, 5, and 10 years, respectively.
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Comment |
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Bicuspid aortic valve is the most common cause of aortic valve disease in children and young adults [6, 9, 12]. Young patients with bicuspid aortic valve frequently have a dilated aortic root because of premature degenerative disease of the aortic root and ascending aorta [20]. Erdheim’s cystic medial necrosis has been described in the arterial wall of the ascending aorta and pulmonary artery in some of these patients [20]. De Sa and colleagues [20] found that degenerative changes in the media of the pulmonary artery are common in normal subjects, but they are more severe in patients with bicuspid aortic valve disease than in those with normal or diseased tricuspid aortic valves. The pulmonary root in some cases may have inadequate elastic fibers and fibrillin in its media to adapt itself to the mechanical stress of the aortic root.
With increasing follow-up, the need for reoperation remains the principal limitation of the Ross AVR and every other type of AVR. The Edinburgh Heart Valve trial and the Veterans Affairs Cooperative study on valvular heart disease showed that the need to replace a mechanical heart valve at 12 years was 8% to 12% and that of a xenograft valve was 26% to 38%, respectively [21, 22]. Reoperation for postoperative AI has been reported with both the root replacement and the subcoronary Ross techniques and remains low [2, 7, 11, 19]. Although relatively low reoperation rates have been reported in the first 5 years postoperatively in many studies, our experience and that of others indicate that a small percentage of patients continue to develop substantial Ross valve regurgitation 5 years after Ross AVR and require reoperation [7, 19]. In our series, 9 of the 14 reoperations on the pulmonary autograft were performed more than 5 years postoperatively and as late as 10 years after the initial Ross AVR (Table 3).
Multiple causes for autograft regurgitation have been identified with the Ross root replacement technique. These include technical problems such as injury to the Ross valve at the time of implantation, geometric annulus and sinotubular junction mismatch, false suture-line aneurysm, endocarditis, and postoperative systemic hypertension that stretches the autograft causing dilation and progressive AI. Progressive dilation of the native aorta above the autograft root may also lead to regurgitation of the Ross valve if the Ross valve sinotubular junction is not reinforced. This latter change can occur with the Ross subcoronary, root inclusion, or root replacement techniques. In our study, in which only full root replacement technique was used, dilation of the pulmonary autograft with progressive AI was the most common indication for reoperation. Moritz and associates [23] reduced the diameter of the aortic annulus and wrapped the pulmonary autograft with an absorbable mesh in a few patients as an attempt to prevent postoperative AI. Pacifico and colleagues [24] described an operative technique in which the entire pulmonary autograft was wrapped with glutaraldehyde-fixed bovine pericardium to prevent dilation. The Ungerleider technique [25] of placing a polyethylene terephthalate fiber (Dacron) sleeve around the autograft was recently introduced to address this concern.
Hokken and colleagues [14] measured the diameters of the unreinforced pulmonary autograft with echocardiography at various time after the Ross procedure and found a significant increase in the diameters of the aortic annulus and sinuses of Valsalva. In most cases, dilation occurred during the first 10 postoperative days. During a mean follow-up of 2.3 years, the aortic annulus increased from 26 to 32 mm in 22 patients, and the diameter of the sinuses of Valsalva increased from 37 to 44 mm in 17 patients. Hokken and associates [14] reported Ross root dilation (up to 55 mm) without the development of AI or need for replacement.
Autograft dilation (z value more than +2.0) after the Ross procedure has been demonstrated in several series [2, 7, 11–14] and has occurred in 31 patients in our series, but only 13 (8%) have developed more than mild regurgitation. In 7 of the 13 the autograft was replaced with a composite conduit containing a mechanical valve. In the other 6 the ascending aorta above the Ross valve was replaced with a Dacron graft and the Ross valve was preserved.
Patients with preoperative dilated ascending aorta (z value more than +2.0) are at increased risk for the late development of progressive ascending aorta dilation of the autograft regurgitation. Since 2001 we have adopted the philosophy of replacing the dilated ascending aorta with an appropriately sized Dacron graft to support the sinotubular junction of the autograft. We have also been more aggressive about using a strip of Dacron fabric at the sinotubular junction of the autograft in adolescents and adults when the ascending aorta is not dilated but is larger than the autograft sinotubular junction. We do not believe that reverting to a subcoronary or inclusion cylinder would be useful in this subset.
Annulus and sinotubular junction reduction and fixation should be considered in all older patients (older than 5 years) with root dilation and predominant AI and in any older patient who has an aortic annular diameter more than 3 mm greater than the pulmonary annulus diameter. Fixation at the sinotubular junction with a strip of Dacron is now routinely done in older children and adults but was not routinely done early in our series. In the last several years we have adopted Elkins’s [5] recommendation to replace the ascending aorta if it is significantly dilated greater than 35 mm. We also routinely treat systemic hypertension aggressively in first 3 to 6 months postoperatively with ß-blockers and angiotensin-converting enzyme inhibitors to prevent autograft dilation and subsequent regurgitation. We believe that the early avoidance of systemic hypertension will allow the autograft to remodel gradually and become more resistant to dilation.
Although the results of this report are encouraging, its primary limitation is the lack of longer-term follow-up. Follow-up of the Ross patient must include regular echocardiographic evaluations of the pulmonary autograft and pulmonary replacement valve. Autograft insufficiency is the most dreaded late complication after the Ross operation, and it may develop late in follow-up if systemic hypertension is not controlled from the outset [5, 24, 25]. Progressive dilation after the expected initial dilation of the neoaortic root and sinus diameters is uncommon [11, 13]. Elkins [5] described evidence of dilation of the Ross AVR annulus after 4 years of follow-up. Schoof and associates [26] did an in vivo study of the pulmonary autograft AVR in rapidly growing pigs and found both growth and dilation of the autograft root with preservation of the normal histologic characteristics of the pulmonary artery wall of the autograft. At the time of sacrifice, the autograft valves were tested for insufficiency, but in vivo valve function was not determined. The Ross International Registry indicates that in 4,200 patients with follow-up, 83% of patients are free of autograft explant at 21 years. Present clinical and experimental evidence does not fully answer whether the Ross root will be a permanent AVR; however, failure and the need for replacement has remained low, and in most patients there has been minimal evidence of progressive dilation. Continued close surveillance by routine annual echocardiograms should be part of the evaluation of patients who have had a Ross AVR. Reoperative treatment of the Ross AVR patients should be based on ascending aortic dilation and autograft and homograft valve function. Patients with significant dilation of the ascending aorta should be offered reoperation for ascending aortic replacement before the Ross valve develops moderate regurgitation. Further long-term follow-up with the modifications outlined here and by others is needed to determine the durability of the Ross root replacement. To date the Ross AVR compares favorably with all other types of AVR and remains the AVR of choice for children and young adults (younger than 60 years) at our institution.
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Discussion |
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I have two questions.
Would there be a root relationship in a child that would preclude you from doing a Ross operation, say a huge size discrepancy or some other issue, that you would say should disqualify that patient for a Ross?
DR BROWN: Well, that’s a great question that I’ve asked Ron Elkins, who has been my mentor about the Ross operation for many years. And in particular in the child younger than 10 years of age, I haven’t used the ascending aortic diameter to dissuade me from doing the Ross. I basically just replaced the ascending aorta in that group of kids and patients.
So I don’t know, I may find out that there is that group that we shouldn’t do the Ross in, and you may have the answer to your own question. If you do, let me know, because I don’t know.
DR FRASER: No, I do not have that answer.
The second part of the issue is that you’ve shown that a younger age at the time of the Ross is a risk factor for root dilation, not necessarily for aortic insufficiency, but for root dilation. But, of course, that’s the group of patients that you want to achieve somatic growth in. So what are you doing with the annulus in those patients?
DR BROWN: Well, obviously, you can’t limit it. My cutoff is about 20 mm. I think an aortic root of 20 mm, at the time of the Ross, is probably big enough through most 2 m2 body surface areas, and there is not going to be much of a gradient. So if I do a Ross and the Ross annulus is less than 20 mm, I don’t reinforce it. And the same for the sinotubular junction, if it’s smaller than 20 mm, I’m not likely to reinforce it.
And that’s why that group has more root dilatation, because there has been no effort to fix either the annulus or the sinotubular junction. So I think it’s expected that the kids who don’t get any of this reinforcement are likely to have more dilatation.
DR EDWARD L. BOVE (Ann Arbor, MI): John, two things struck me as I listened to your presentation. One, Tirone David has reported histologic evidence that the pulmonary root, in addition to the aortic root, may be abnormal in patients whose original diagnosis was a bicuspid aortic valve. Did you look at that as a risk factor for late root dilatation?
DR BROWN: We didn’t specifically, Ed, because 71% of our patients had bicuspid aortic valves anyway. So we didn’t have a group big enough.
And I haven’t specifically gone back—and answered your question—to look at the ones with bicuspid valves versus tricuspid valves. But as a general rule, we have not let preoperative diagnosis of bicuspid aortic valve dissuade us from proceeding with the Ross. It’s not a good answer to your question, but we just haven’t analyzed that.
DR BOVE: Another issue relates to annular dilatation versus root dilatation, as we frequently interchange the two. As we have seen in our patients, you can stabilize the annulus and the sinotubular junction, but the sinuses of Valsalva will still dilate, which is the real problem.
The other part about your presentation that struck me was that you identified young age as a risk factor for root dilatation, which is completely opposite of what we found. In our series, young patients, and by that I mean infants and neonates, have not shown much evidence of late root dilatation as they grow. The annulus itself grows appropriately and the z scores, which start out large because the pulmonary root is big, come back down toward normal, and then grow proportionately, but root dilatation has been significantly less in these patients compared with the older ones. Do you have any idea why you think that happens in your younger patients?
DR BROWN: Well, first of all, the number of patients that we have in the infant group is small. I think there are 6 or 7 patients.
And then when we looked at the group under 5 years of age, there are only about 25 or 30 patients. We haven’t seen any aortic root dilatation in the infant group at all, and our results would mimic yours. I think it’s just we don’t have many in that age category. And a lot of ours are teenagers as you saw on the age distribution slide.
DR GERHARD ZIEMER (Tübingen, Germany): Very good results, John, but still you defined the group that is at risk for later dilatation and insufficiency, namely, the bicuspid aortic valve patients, especially when you have already a dilatation of 40 mm. In our adult patients, 45- or 50-year-old patients with aortic insufficiency, bicuspid valve,and a 4-cm ascending aorta diameter, we replace routinely the ascending aorta also if the primary indicated surgery was mechanical valve replacement.
I personally don’t think that it is a good idea to replace the ascending aorta and have the autograft underneath it, because you put a lot of stress to this root and maybe even further have the development of root dilatation when distally you have the noncompliant Dacron tube. So I would rather prefer, then, in these patients, not to do the Ross operation.
And furthermore, what do you think will happen to these patients who are now at the age of 20, 25 years, who have already now a 4-cm autograft? When will you go and replace the ascending aorta? Will it be at 5 cm, 5.5 cm, as we do with a normal aorta nowadays? So what is your plan and what do you expect?
DR BROWN: Well, first of all, we have been burned by not replacing those dilated aortas at the time of the initial Ross and have had to come back when they’re greater than 5 cm in diameter. And to me, the tradeoff of a reoperation at 10 or 15 or 20 years in a young person is worth it. I mean, to redo root replacement is not that big a deal. But if I’ve given the patient 15 or 20 years of an autograft and no anticoagulation and the potential, if it’s a young lady, of being able to have children, then I think it’s a worthwhile tradeoff.
We have not seen replacing the ascending aorta as being a major risk factor for root dilatation of the sinuses of Valsalva, but it may well be that we just haven’t followed those patients long enough. So it’s a little bit of a difference of opinion. Maybe it’s just going to take longer-term follow-up to figure out if that’s a bad idea, but that’s what we’re doing.
DR JOHN E. MAYER (Boston, MA): I would just call your attention to two things.
One is that there is, I’m pretty sure it’s now in print, a manuscript from Fred Schoen, who is a cardiac pathologist at the Brigham, where they have actually looked at the wall of Ross aortic root replacements, in other words, when you’re doing a Ross as a cylindrical conduit containing the valve. And at least in the 8 or 10 patients, I think it is, that they have seen, the aortic wall is acellular, dead, no cells. And I think if you’re looking for mechanisms for potentially why you’re more likely to see this happen in an older patient, but maybe not in a younger patient, like Ed describes, then I think revascularization, or vascular blood supply to the root, may be the mechanism that explains the difference. I suspect the patients may revascularize an autograft when it’s small, because it’s a baby, and because babies revascularize things better than adult patients. So that’s one observation I would just call your attention to.
The second thing that I would ask you about is if you, in your wrapping of the aortic root, try to tailor that so that you maintain the 3-dimensional geometry of sinuses of Valsalva that I think have been known for a long time, back to da Vinci, are important for normal semilunar valve function?
DR BROWN: Well, first of all, John, thank you for your comment about the cellularity of the adult ascending aorta. I wasn’t aware of that, and it might be interesting to go back. I think we have pathology on most of those. I would have thought I would have paid attention to that if they were dead, but it sounds like a worthwhile study to do.
And in answer to your question, I haven’t used a wrap around the aortic root, and I’m trying to decide whether I think that’s a good idea or not. But these three techniques have been advocated in those patients who you really want to do a Ross on but you’re afraid are going to develop aortic root dilatation.
There may be people in the audience that can answer that question. Is Ross Ungerleider here?
DR ROSS M. UNGERLEIDER (Portland, OR): I just walked in, John, I’m sure it was a great presentation. It’s hard to walk down the hall and not keep getting stopped, and so I apologize for being a little late. I thought that topic might come up.
We don’t know what to make of autograft dilatation, because the range seems to be people saying they never see it, to people saying they have seen it in some patients. Clearly, it does occur in some patients.
And we have felt that there is very little downside to inserting the autograft in a Dacron tube. At least we’ve done it now in 15 patients, dating back to October of last year, so we have about a year and a third of follow-up of those patients. It has been a reproducible operation in all of those patients. There is no autograft dilatation that we have been able to ascertain so far, but it’s very short-term follow-up.
And in the patients in whom we do this, we most often also replace the ascending aorta, because in those patients the aorta is dilated. We have 1 patient, in fact, who had a form of Marfan’s syndrome, and we did the same operation in that patient, and so far it’s worked out fine.
I don’t know the long-term fate of the autograft. I think that we have to know at least 10 years or more outcome data to be able to have comparable information to what you have about a nonstructured Ross. We call this the structured Ross.
And I also don’t know what’s going to happen in terms of autograft dilatation in these patients. It’s hard to imagine that an autograft would dilate when it’s totally surrounded. It’s not a wrap, it’s really totally inserted in Dacron. So it’s hard to imagine that it would dilate, but we have to have that data.
So we are reserving this operation for adult patients, or children who have grown to full size, especially those who have dilated aortas and are going to have the whole aorta replaced. We think it makes a lot of sense. We have IRB (institutional board review) approval for this. And it does get into when does a modification of an operation get into the ethical question of patients having to be consented for an operation that’s a new operation. I don’t think this is. There have been people who supported Ross procedures in the past.
So we’re doing this. Our technique has been reported. We hope to send into one of the upcoming meetings some short-term follow-up. I just, I think we have to be careful, whenever we change an operation, to too quickly assume it’s going to be an improvement. But it seems to make sense for adult patients. I think autograft dilatation does occur.
And the problem is, and I’ll just say this one last thing, is it’s sort of like the data that came out of the IOM (Institute of Medicine), it doesn’t matter whether there have been 44,000 or 98,000 deaths due to medical errors, the fact is people believe it’s true. Cardiologists believe that the autograft is a bad operation because there is a potential for autograft dilatation. And as long as they believe that that’s a problem, they won’t refer patients for a Ross operation. And I still personally think it’s about the best operation we’ve got for aortic valve replacement for young adults. So it’s nice for us to come back with an improvement that might at least satisfy that problem.
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This article has been cited by other articles:
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  A. C. Kollar, S. D. Lick, D. M. Palacio, and R. F. Johnson Jr Ross procedure with a composite autograft using stretch gore-tex material. Ann. Thorac. Surg., October 1, 2009; 88(4): e34 - e36. [Abstract] [Full Text] [PDF]
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J. W. Brown, M. Ruzmetov, A. Shahriari, M. D. Rodefeld, Y. Mahomed, and M. W. Turrentine Midterm results of Ross aortic valve replacement: a single-institution experience. Ann. Thorac. Surg., August 1, 2009; 88(2): 601 - 607. [Abstract] [Full Text] [PDF]
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J. J.M. Takkenberg, L. M.A. Klieverik, P. H. Schoof, R.-J. van Suylen, L. A. van Herwerden, P. E. Zondervan, J. W. Roos-Hesselink, M. J.C. Eijkemans, M. H. Yacoub, and A. J.J.C. Bogers The Ross Procedure: A Systematic Review and Meta-Analysis Circulation, January 20, 2009; 119(2): 222 - 228. [Abstract] [Full Text] [PDF]
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A. Frigiola, M. Ranucci, C. Carlucci, A. Giamberti, R. Abella, and M. Di Donato The Ross Procedure in Adults: Long-Term Follow-Up and Echocardiographic Changes Leading to Pulmonary Autograft Reoperation Ann. Thorac. Surg., August 1, 2008; 86(2): 482 - 489. [Abstract] [Full Text] [PDF]
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= patients with normal size of autograft; 
= patients with dilated autograft). (P 10, P 90 = 10th and 90th percentiles.)
