Ann Thorac Surg 2008;85:808-809. doi:10.1016/j.athoracsur.2007.08.060
© 2008 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited Commentary
Emile A. Bacha, MD
Department of Cardiac Surgery, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115
(Email: emile.bacha{at}cardio.chboston.org).
The present article by Kadner and colleagues [1] is a retrospective review of an 11-year experience with the Ross procedure in 52 consecutive children less than 15 years of age. They describe a fairly high overall mortality of 15.4%, centered mostly on 5 infants (9.6%) who were less then 2 months old and who had died in the hospital. All 5 infants had undergone a Ross procedure for acute aortic insufficiency (AI), occurring either after balloon dilation or surgical valvotomy. Follow-up was complete for only 38 patients (73%), which is a very low follow-up rate. In the group of patients that was followed-up, freedom from any reoperation was 57% at 10 years, and freedom from right ventricular outflow tract surgery was 60% at 10 years. The mortality rate is higher than reported from other centers [2–4], but this series includes more critically ill and younger infants than many other series [5, 6]. Given that young age, prematurity, and low birth weight have been consistently documented as risk factors [7], a higher mortality would be expected.
There are two major contemporary questions with the Ross procedure, and unfortunately this article does not help answer either one of these questions. The first question is whether the Ross procedure or Ross-Konno procedure should be used in the sick infant with critical aortic stenosis presenting in cardiogenic shock and severe left ventricular dysfunction. These patients often have additional anatomic anomalies, such as hypoplastic aortic annulus, aortic coarctation, endocardial fibroelastosis, mitral stenosis, and other left-sided lesions. None of the available management options available to these patients are curative. Depending on anatomic details, a Ross procedure, Ross-Konno procedure, balloon aortic valvuloplasty, surgical valvuloplasty, stage I Norwood, and even mechanical support as a bridge to myocardial recovery can be attempted. The pulmonary autograft provides the best left ventricular outflow tract patency and neoaortic valve competency, but at the cost of major surgery with (among other things) its attendant risk of endothelial membrane injury and development of anasarca that is typical of this patient population. For isolated critical aortic stenosis, we have favored primary aortic balloon valvuloplasty, followed by aortic valve repair in case significant AI develops [8]. In the vast majority of cases, an aortic valve replacement can be avoided [8].
The second important contemporary issue is the fate of the neoaortic root at mid-term to long-term. This is less important in infants and young children who need growth, but critically important in otherwise healthy teenagers with bicuspid aortic valve disease (and normal size aortic annuli) who often represent the bulk of elective aortic valve surgery. Here, it is the risk of developing AI, an aneurysmal aortic root, and the need for right ventricle–pulmonary artery conduit interventions that is important. Clearly, these questions will not be answered by the present study, with more than a quarter of patients lost to follow-up. Other larger studies with better follow-up have established an increasing risk of neo-AI [3], and thus, in those teenagers who need aortic valve surgery, especially with AI as the predominant lesion [4], an aortic valvuloplasty or a prosthetic valve replacement may be preferable. This series reflects senior expertise, but one remains frustrated for solid data that would help inform such critical clinical decision making.
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References
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- Kadner A, Raisky O, Degandt A, et al. The Ross procedure in infants and young children Ann Thorac Surg 2008;85:803-809.[Abstract/Free Full Text]
- Ohye RG, Gomez CA, Ohye BJ, Goldberg CS, Bove AL. The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function Ann Thorac Surg 2001;72:823-830.[Abstract/Free Full Text]
- Pasquali SK, Cohen MS, Shera D, Wernovsky G, Spray TL, Marino BS. The relationship between neo-aortic root dilation, insufficiency, and reintervention following the Ross procedure in infants, children and young adults J Am Coll cardiol 2007;49:1806-1812.[Abstract/Free Full Text]
- Laudito A, Brook MM, Suleman S, et al. The Ross procedure in children and young adults: a word of caution J Thorac Cardiovasc Surg 2001;122:147-153.[Abstract/Free Full Text]
- Brown JW, Ruzmetov M, Fukui T, Rodefeld, MD, Mahomed Y, Turrentine MW. Fate of the autograft and homograft following Ross aortic valve replacement: reoperative frequency, outcome, and management J Heart Valve Dis 2006;15:253-259.[Medline]
- Al Halees Z, Pieters F, Qadoura F, Shahid M, Al-Amri M, Al-Fadley F. The Ross procedure is the procedure of choice for congenital aortic valve disease J Thor Cardiovasc Surg 2002;123:437-441.[Abstract/Free Full Text]
- McCrindle BW, Tchervenkov CI, Konstantinov IE, et al. Congenital Heart Surgeons Society. Risk factors associated with mortality and interventions in 472 neonates with interrupted aortic arch: a Congenital Heart Surgeons Society study. J Thorac Cardiovasc Surg 2005;129:343-350.[Abstract/Free Full Text]
- McElhinney DB, Lock JE, Keane JF, Moran AM, Colan SD. Left heart growth, function, and reintervention after balloon aortic valvuloplasty for neonatal aortic stenosis Circulation 2005;111:451-458.[Abstract/Free Full Text]
Related Article
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The Ross Procedure in Infants and Young Children
- Alexander Kadner, Olivier Raisky, Alexandra Degandt, Daniel Tamisier, Damien Bonnet, Daniel Sidi, and Pascal R. Vouhé
Ann. Thorac. Surg. 2008 85: 803-808.
[Abstract]
[Full Text]
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