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Ann Thorac Surg 2007;84:1330
© 2007 The Society of Thoracic Surgeons
Erasmus MC-Sophia, Department of Pediatric Cardiology, Dr Molewaterplein 60, Rotterdam, 3015 GJ the Netherlands
(Email: a.tenharkel{at}erasmusmc.nl).
The Ross operation was introduced in 1967 by Donald Ross. It became an important alternative for prosthetic valves in patients who needed aortic valve replacement. The major advantages are that it has low thrombogenicity resulting in avoidance of anticoagulant therapy and the potential to grow in children. Patients who benefit most from the Ross operation are children, young adults with an active lifestyle that can interfere with anticoagulant therapy, and women in childbearing age. Despite these advantages, long-term follow-up studies now show substantial reoperation rates. The main reasons for reoperation are the degeneration of the allograft in the pulmonary position and aortic root dilatation leading to progressive aortic insufficiency. Some studies describe better results by using the subcoronary implantation technique or the inclusion cylinder technique. However, as yet there is no definite answer to the high incidence of autograft failure in these patients.
In their study, Stewart and colleagues [1] report the effects of aortic annuloplasty on aortic root dilatation in a group of children who underwent the Ross operation. In patients in whom the aortic annulus was larger as compared with the pulmonary autograft, the authors developed a reduction annuloplasty technique and reduced the size of the aortic annulus to 1 to 2 mm smaller than the measured pulmonary annulus. Twenty-six children and young adults who did undergo the annuloplasty technique were compared with 20 patients who had a Ross procedure without annuloplasty. During 65 ± 36 months of follow-up, all patients remained in good health and there was no early or late mortality. However, 5 patients required reoperation for neoaortic valve revision or replacement for autograft failure resulting in significant aortic regurgitation. There was no difference in the rate of reoperation between the annuloplasty and no annuloplasty groups. Even more, the frequency of aortic root dilatation was similar between these two groups. The authors concluded that their study failed to demonstrate that reduction annuloplasty prevents the occurrence of aortic root dilatation and neoaortic regurgitation in patients undergoing the Ross operation.
Although the annuloplasty technique as described by the authors did not result in prevention of aortic root dilatation, this study again shows the very low mortality and good long-term survival after the Ross operation. Despite its shortcomings, the Ross operation still remains an important operation for aortic valve replacement, especially in young children and women of childbearing age. Future studies may include newer technologies as tissue engineering, and hopefully are able to combine the good survival rates with prevention of aortic root dilatation.
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