HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alessandro Frigiola Marco Ranucci Alessandro Giamberti Raul Abella Marisa Di Donato Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Frigiola, A. Articles by Di Donato, M. Search for Related Content PubMed PubMed Citation Articles by Frigiola, A. Articles by Di Donato, M. Related Collections Valve disease Related Article

---

Original Articles: Adult Cardiac

The Ross Procedure in Adults: Long-Term Follow-Up and Echocardiographic Changes Leading to Pulmonary Autograft Reoperation

^a Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
^b Department of Cardiothoracic–Vascular Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy

Accepted for publication April 1, 2008.

^_* Address correspondence to Dr Ranucci, Department of Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milan, 20097, Italy (Email: cardioanestesia{at}virgilio.it).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background: This is a clinical investigation of the mid- to long-term follow-up of the Ross procedure in adult patients. The primary end point is to explore the incidence and risk factors for a reoperation on the pulmonary autograft. The secondary end points are to explore the incidence of neoaortic root dilation and valve regurgitation, and the echocardiographic profile leading to a reoperation.

Methods: Ross operations were done in 110 adults who received at least two echocardiographic examinations for a mean follow-up time of 82 months (range, 5 to 155 months). Kaplan-Meier and Cox regression analyses were applied to assess freedom from events and risk factors for events.

Results: Freedom from reoperation on the pulmonary autograft, neoaortic root dilation, and moderate-severe neoaortic valve regurgitation were, respectively, 91.4%, 50%, and 70% at 12 years. The main risk factor for a reoperation was the degree of neoaortic valve regurgitation within the first 2 years of follow-up. Patients requiring an early (4 years) reoperation had early and severe pulmonary autograft valve regurgitation, and no neoaortic root dilation. Patients needing a late (>4 years) reoperation had severe neoaortic root dilation and severe neoaortic valve regurgitation. The left ventricular end-diastolic diameter at the third year of follow-up was a risk factor for late reoperation.

Conclusions: The Ross operation in adults is a safe procedure with good clinical results in mid- to long-term follow-up. Early reoperations are due to early neoaortic valve regurgitation, wheras late reoperations are due to progressive neoaortic root dilation.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
The Ross procedure was first described in 1967 [1] and is an alternative to the use of mechanical, biologic, and homograft valves for aortic valve disease. Patients receiving a Ross procedure do not need anticoagulation, and in children, there is the possibility that the neoaortic autograft may follow somatic growth [2–4]. For these reasons, it is suggested mainly in infants, children, and young adults.

The in-hospital outcome of the Ross procedure is generally characterized by low mortality and morbidity both in adult and pediatric patients [5–10]. However, intermediate- to long-term follow-up studies have highlighted the time-related modifications occurring both at the pulmonary autograft and at the homograft site. Progressive dilation of the neoaortic root with associated valve regurgitation has been reported [11–17], whereas homograft calcification and stenosis are rare (<5%) and represent a minor point of concern [5, 9, 10, 14, 17].

The main criticism of the Ross procedure is the risk of a reoperation at the pulmonary autograft site, subsequent to progressive neoaortic root dilation and valve regurgitation. Many authors have addressed this point with clinical and echocardiographic follow-up studies [5, 9, 10–17]. One of the critical points in monitoring the time-related changes of the autograft dimensions is that in infants and children it is quite difficult to separate somatic growth from pathologic dilation. Authors who have studied a mixed (infants to young adults) population tried to overcome this problem with a standardization of the measurements according to the body surface area [11, 17] or using z scores and normal aortic valve and root measurements [16]. But the suitability of including infants and young adults together in this kind of analysis remains arguable. Some studies have concentrated only on adult patients [5, 6, 8, 9, 12–14] based on intermediate- to long-term follow-up, but only a few report comprehensive echocardiographic follow-up [9, 12, 13].

The present study is based on a single-institution experience with the Ross procedure in adults. The primary end point of the study was to assess the intermediate- to long-term outcome of the Ross procedure in adult patients in terms of incidence and risk factors for a reoperation at the autograft site. Secondary end points were (1) the presence and degree of autograft valve regurgitation, (2) the presence and extent of autograft root dilation, and (3) right-heart time-related echocardiographic changes and need for reoperation at the level of the homograft conduit.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patients
From August 2, 1994, through February 2, 2007, 178 patients underwent a Ross procedure at our institution. The present analysis was conducted on adult patients only. The entry criterion was an operation performed at an age of 17 years or older. This retrospective analysis was conducted on 110 patients who fulfilled this condition. The study was approved by the local Ethical Committee, and because it was a retrospective analysis, the need for informed consent of the patients was waived. All the patients provided a general consent to the scientific treatment of their data, in anonymous form, before undergoing the operation at our institution.

Surgical Procedure
All the operations were conducted using a full-root technique, under moderate hypothermia and cold intermittent antegrade blood cardioplegia and topical cooling of the heart. The diameters of the annuli of the aortic and pulmonary valves were measured intraoperatively using transesophageal echocardiography. The morphology of the pulmonary valve was also inspected and the diameter measured using calibrated dilators after surgical excision of the valve.

The pulmonary autograft was excised from the right ventricular outflow tract, together with a 2- to 3-mm muscle rim, while the heart was beating. The right and left coronary arteries were mobilized with large buttons, and the aortic root was removed. The pulmonary autograft was implanted as a free root into the aortic position using separated simple 4-0 braided suture for the proximal anastomosis and a 5-0 polypropylene running suture for the distal anastomosis. The coronary artery buttons were implanted into their respective sinuses using a running suture of 5-0 polypropylene.

After the completion of the left-sided aspect of the operation, a pulmonary artery homograft was implanted on the right ventricular outflow tract using two running sutures of 5-0 polypropylene for the distal anastomosis and 4-0 polypropylene for the proximal anastomosis.

Data Collection
All patients received an echocardiographic study at our institution before the operation, and the study was repeated before hospital discharge. The follow-up was based on echocardiographic studies performed during the following years either at our institution or at other hospitals.

The echocardiographic data collected were presence of a bicuspid aortic valve, the degree of aortic valve (or autograft valve) regurgitation or stenosis, and the degree of homograft valve regurgitation or stenosis. Valve regurgitation was assessed as grade 0 (absent or trace, jet width/left ventricular outflow tract < 0.2); grade 1 (mild, jet width/left ventricular outflow tract 0.2 to 0.39); grade 2 (moderate, jet width/left ventricular outflow tract 0.4 to 0.59); and grade 3 (severe, jet width/left ventricular outflow tract 0.6).

Other echocardiographic data collected were native pulmonary valve diameter, left ventricular end-systolic and end-diastolic diameters and volumes; left ventricular ejection fraction; left ventricular posterior wall end-systolic and end-diastolic posterior thickness, interventricular septum end-systolic and end-diastolic thickness; left ventricular mass; left atrial end-systolic diameter; right ventricular end-diastolic diameter; aortic valve (or autograft valve) diameter; aortic (or autograft) root diameter at the level of the sinuses of Valsalva, and ascending aorta diameter.

Autograft root dilation was defined as a diameter at the level of the sinuses of Valsalva of 40 mm or more.

Statistics
Summary statistics are expressed as means and standard deviation (or standard error in figures), median and range, and number and percentage when appropriate. A Kaplan-Meier analysis was performed to assess freedom from neoaortic root dilation, moderate to severe neoaortic valve regurgitation, and reoperation on the pulmonary autograft site. Cox regression analysis was applied to preoperative demographics and echocardiographic data to establish if the preoperative profile was associated with reoperation on the pulmonary autograft site. Postoperative echocardiographic data within the first 24 months after the Ross operation were entered in the same Cox regression analysis to assess the presence of predictive variables for reoperation on the pulmonary autograft site. The 24-month postoperative period was considered because no patient required a reoperation within this period.

The echocardiographic profile leading to a reoperation was investigated by comparing the echocardiographic data immediately before the reoperation with the echocardiographic data not associated with a reoperation. A Student t test for independent variables was applied for between-group comparisons.

The follow-up was divided into 12-month intervals, producing seven intervals for the first 7 years, with the eighth interval being represented by a follow-up of 8 years or more. Relevant echocardiographic data have been analyzed according to these time intervals and expressed as mean, interquartile range, and extreme values. Differences between patients who did and did not require reoperation were tested using a Student t test for independent variables.

Variables associated with the need for a reoperation were tested for predictability with a receiver operating curve (ROC) analysis, and adequate cut-off points were defined according to their sensitivity and specificity power. For variables that were predictive of reoperation, a risk function was calculated using a logistic regression analysis. Owing to the limited number of positive events, no multivariable analyses were performed.

The association between echocardiographic variables and the primary dependent variable (reoperation) was assessed with logistic regression analyses. The association within different echocardiographic variables was assessed using linear or polynomial regression analyses. For all the tests, a value of p < 0.05 was considered significant.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Demographics and echocardiographic data of the patient population immediately before the operation are reported in Table 1. Ross procedure operative data are provided in Table 2. There was no in-hospital mortality.

The freedom from reoperation rate, according to a Kaplan-Meier actuarial survival curve (Fig 1), was 91.4% at 12 years of follow-up but decreased to 61% after this time interval. However, only 5 patients exceeded a follow-up time of 12 years. Cox regression analysis failed to find any association between preoperative data and the need for a reoperation. Conversely, a significant (p = 0.002) association was found between the degree of neoaortic valve regurgitation within the first postoperative 24 months and the need for a reoperation on the pulmonary autograft site.

View larger version (25K): [in this window] [in a new window]   Fig 1. Kaplan-Meier curves for autograft reoperation (solid line), moderate or higher autograft valve regurgitation (dashed line), and autograft root diameter of 40 mm or more.

View larger version (26K): [in this window] [in a new window]   Fig 2. Pulmonary autograft diameters over time for the sinotubular junction (top line), autograft root (middle line), and autograft valve annulus (bottom line) are presented with the standard error of the mean (error bars).

Echocardiographic Changes Associated With Pulmonary Autograft Reoperation
The echocardiographic profile immediately before the reoperation was explored and compared with the echocardiographic data of patients not needing a reoperation (Tables 4 and 5). Four variables significantly differed between groups: left ventricular end-diastolic diameter, left ventricular posterior wall end-diastolic thickness, interventricular septum diastolic thickness, and aortic diameter at the level of the sinuses of Valsalva.

The time-dependent course of these two echocardiographic variables was explored using 12-month time intervals during the follow-up period (Fig 3 and Fig 4). In both of these analyses, the data relative to the patients undergoing reoperations were of course incomplete after 36 months owing to the progressive loss of data from patients receiving the reoperation. No differences were seen with respect to the autograft diameter; conversely, during the third year of follow-up, patients subsequently needing a reoperation had a significantly larger left ventricular end-diastolic diameter.

View larger version (29K): [in this window] [in a new window]   Fig 3. Box and whisker plots show the left ventricular end-diastolic diameter over time in patients requiring reoperation (gray boxes) on the pulmonary autograft vs patients not requiring reoperation (white boxes). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The whiskers mark the 90th and 10th percentiles.

View larger version (27K): [in this window] [in a new window]   Fig 4. Box and whisker plots show the pulmonary autograft root diameter over time in patients requiring reoperation (gray boxes) on the pulmonary autograft vs patients not requiring reoperation (white boxes). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The whiskers mark the 90th and 10th percentiles.

View larger version (25K): [in this window] [in a new window]   Fig 5. Mean pulmonary autograft valve regurgitation over time in patients requiring reoperation (black squares) on the pulmonary autograft vs patients not undergoing reoperation (white squares). Error bars designate the standard error of the mean.

Right Ventricular Outflow Tract Dysfunction and Reoperation
The homograft valve was found moderately regurgitant in 12 patients (11%) and severely regurgitant in 2 (1.8%) during the follow-up period. No significant time-related changes in the homograft transvalvular gradient were detected. One of the 2 patients with severe homograft valve regurgitation required a reoperation after 45 months due to concomitant severe aortic regurgitation and congestive heart failure symptoms; the other has severe aortic regurgitation and is scheduled for reoperation in the next few months, 11 years after the Ross procedure. There is a significant (p < 0.001) dependency of the homograft valve regurgitation on the autograft valve regurgitation during the follow-up.

Three patients needed a reoperation (homograft substitution) due to significant homograft stenosis. Four patients (3.6%) were reoperated on at the homograft site, 3 for homograft stenosis and 1 for homograft valve regurgitation and concomitant neoaortic valve regurgitation.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Many articles have addressed the outcome after Ross procedures in adults, children, and mixed populations. Freedom from reoperation on the pulmonary autograft is 92% at 10 years in the series reported by Brown and coworkers [17], 97% at 5 years in the limited series of adult patients reported by Fullerton and coworkers [6], 94.9% at 10 years in the 264 adult patients reported by Yacoub and coworkers [5], 87.4% in a series of 103 adult patients reported by Settepani and coworkers [14], and 91% at 6 years reported by David and coworkers [12] in 118 adult patients. In a recent article, Pasquali and coworkers [16] reported a freedom from reoperation on the pulmonary autograft of 88% at 6 years in a mixed patient population. Elkins [8], in a similar mixed patient series, reported a freedom from reoperation on the pulmonary autograft at 8 years of follow-up of 95% for patients aged older than 45 years and 70% for patients between 18 and 45 years old. Finally, in a mixed population of 119 patients, Kouchoukos and coworkers [9] found a freedom from reoperation rate on the pulmonary autograft of 95%, 80%, 75% at 5, 7, and 10 years, respectively.

In our series of adult patients, the freedom from reoperation rate on the pulmonary autograft was 91% after 10 years of follow-up—with 25 patients entering the last interval—and is, therefore, within the best range reported in the previous articles. This information, together with the absence of in-hospital mortality, the low rate of postoperative complications, and the low rate of reoperations on the homograft conduit, allows us to conclude that the Ross operation can be safely and effectively performed in adult patients.

In our analysis, we could not identify any preoperative predictor of reoperation on the pulmonary autograft. Other authors could find different predictors in a different set of patients. In a mixed patient population, Pasquali and coworkers [16] identified the presence of a ventricular septal repair before the Ross procedure as a significant predictor of neoaortic reintervention, with trends for patients with an original diagnosis of aortic insufficiency and a long cardiopulmonary bypass time. The only predictor in our series of reoperation on the pulmonary autograft was the degree of neoaortic valve regurgitation in the first 24 months after the operation.

Freedom from neoaortic root dilation (40 mm) was 59% at 10 years of follow-up. Comparisons with other series are difficult due to the use of different cutoff values for defining neoaortic root dilation. Using z scores, Pasquali and coworkers [16] reported freedom from dilation of less than 30% at 8 years, with a mean increase of 0.18 cm/y, and using a cutoff value at 37 mm, Simon-Kupilik and colleagues [13] found the freedom from dilation was 45% at 7 years. In a subpopulation of adults, Brown and coworkers [17] reported a freedom from dilation rate of 86% at 10 years (z value > +2.0). David and coworkers [12] demonstrated that the neoaortic valve annulus did not dilate during a 3-year follow-up, which was confirmed by our data; whereas similar to our results, the neoaortic root diameter at the level of the sinuses of Valsalva increased at a rate of about 0.28 mm/y.

The freedom from moderate to severe neoaortic regurgitation was 70% in our follow-up at 10 years, which was higher than the corresponding 60% rate reported by Pasquali and colleagues [16] at 6 years.

Practically all the relevant studies addressing the reoperation rate on the pulmonary autograft after Ross procedures report neoaortic root dilation with concomitant neoaortic valve regurgitation as an indication for reintervention. In a few patients, an isolated severe aortic regurgitation without excessive neoaortic root dilation was also an indication. Considering the experiences reported in adult patients, Yacoub and coworkers [5] report aortic regurgitation and concomitant root dilation in 10 of 11 reoperated on patients (the remaining patient had an autograft dissection); Kouchoukos and coworkers [9] report 6 of 10 reoperated on patients with an aortic regurgitation and neoaortic root or ascending aorta dilation, 3 with aortic regurgitation without neoaortic root dilation and 1 with isolated pulmonary autograft dilation. Finally, Brown and coworkers [17] report 7 adult patients requiring a reoperation on the pulmonary autograft: 6 had aortic regurgitation with concomitant neoaortic root dilation, and had 1 a false aneurysm of the autograft.

The general tendency is to consider aortic regurgitation to be the main determinant of a reoperation, and that progressive neoaortic root dilation is the leading determinant of aortic regurgitation. However, different mechanisms leading to neoaortic valve regurgitation have been reported. Technical problems during the Ross operation may lead to early aortic regurgitation and the need for reoperation due to previous cardiac operations [16], quadricuspid pulmonary valve [14], or unspecified intraoperative technical problems [10].

In our series, early (<24 months) postoperative neoaortic valve regurgitation was the only predictor of the overall reoperation rate on the pulmonary autograft. Of the 8 patients who required a reoperation on the pulmonary autograft, 4 had severe aortic regurgitation without excessive neoaortic root dilation (always <40 mm). These 4 patients had left ventricular dilation and required a relatively early reoperation, always between 2 and 4 years after the Ross operation.

Conversely, the patients undergoing late reoperation all had neoaortic root dilation, which was associated with severe neoaortic valve regurgitation. We are inclined to consider that the patients in the first group had an intraoperative technical problem leading to a suboptimal result and that the degree of this early aortic regurgitation had rapidly increased, which predisposed the patient to left ventricular dilation and the need for a reoperation. Conversely, the pathophysiologic route leading to reoperation is probably progressive neoaortic root dilation, with subsequent onset of neoaortic valve regurgitation. The different pathways leading to a reoperation on the pulmonary autograft are summarized in Fig 6.

View larger version (28K): [in this window] [in a new window]   Fig 6. Echocardiographic pattern leading to early or late reoperation on the pulmonary autograft. (ADSV = autograft diameter at the level of the sinuses of Valsalva; AR = aortic regurgitation; EDLVD = end-diastolic left ventricular diameter.)

The echocardiographic profile leading to a reoperation on the pulmonary autograft is represented by left ventricular dilation, decreased left ventricular muscle mass at the level of the posterior wall and interventricular septum, neoaortic root dilation at the level of the sinuses of Valsalva, and severe neoaortic valve regurgitation. All these variables may be useful in monitoring the postoperative course of an adult patient undergoing a Ross operation; however, the best predictor of a (late) reoperation on the pulmonary autograft is relatively early (third year after the operation) left ventricular dilation. A left ventricular end-diastolic diameter exceeding 65 mm has a good predictive value. Conversely, early (<4 years) reoperations are predicted by the degree of neoaortic valve regurgitation during the first 2 postoperative years.

In our study, we can confirm that right-sided problems after a Ross procedure exist but are of limited impact. Only 3.6% of our patients needed a reoperation on the homograft, basically due to homograft valve stenosis. Homograft valve regurgitation is rare and appears to be related to autograft valve regurgitation leading to left ventricular dilation, left atrium dilation, and increased pressure, with a subsequent increase in right-sided afterload. The rate of reoperations on the homograft is in agreement with the previously reported experiences, where it ranged from 1% to 4% [5, 9, 14].

Study Limitations and Strength
This is a single-institution study, and we cannot be sure that our results are applicable to every patient receiving a Ross procedure. The postoperative echocardiographic examinations were not all performed in our institution, and this could introduce a bias in the measurements, although they are quite common and well-defined measures. Our study was not designed to address histologic changes induced by the operation or to correlate them with the outcome variables.

This study was only focused on adult patients. This choice limited our patient series but allowed us to avoid the use of theoretic "normal" echocardiographic values to standardize the measures obtained by different sized patients or to overcome the problem represented by changes induced by the natural growth of the patient.

The main strength of the present study is that we could collect many postoperative serial echocardiographic examinations, thereby identifying which variables may be of interest in monitoring the postoperative course after a Ross operation and which values should be considered a "warning signal" for a possible reoperation on the pulmonary autograft.

Conclusion
Our experience confirms the validity of the Ross operation for the treatment of aortic valve disease in adults. However, it appears that a patient with a surgical result that is "less than perfect" in terms of neoaortic valve competence is at high risk for an early reoperation on the pulmonary autograft. Excluding these patients, there is a tendency towards neoaortic root dilation that may lead a limited number of patients (<10%) to a reoperation within the first 10 years after the operation. This progression towards a reoperation is accompanied by left ventricle dilation that may be predictive for reoperation at postoperative year 3. The general trend towards the neoaortic root dilation will probably lead more patients to be reoperated on at the pulmonary autograft site in the next years, and the magnitude of this event will be better defined by further 15- to 20-year follow-up studies.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft Lancet 1967;2:956-958.[Medline]
2. Elkins RC, Knott-Craig CJ, Ward KE, et al. Pulmonary autograft in children: realized growth potential Ann Thorac Surg 1994;57:1387-1394.[Abstract]
3. 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]
4. Marino BS, Wenovsky G, Rychik J, et al. Early results of the Ross procedure in simple and complex left heart disease Circulation 1999;100(suppl II):II162-II166.[Medline]
5. Yacoub MH, Klieverik LMA, Melina G, et al. An evaluation of the Ross operation in adults J Heart Valv Dis 2006;15:531-539.[Medline]
6. Fullerton DA, Fredericksen JW, Sundaresan S, Horvath KA. The Ross procedure in adults: intermediate-term results Ann Thorac Surg 2003;76:471-477.[Abstract/Free Full Text]
7. Jaggers J, Harrison JK, Bashore TM, Davis RD, Glower DD, Ungerleider RM. The Ross procedure: shorter hospital stay, decreased morbidity, and cost effective Ann Thorac Surg 1998;65:1553-1557discussion 1557–8.[Abstract/Free Full Text]
8. Elkins RC. The Ross operation: a 12-year experience Ann Thorac Surg 1999;68:S14-S18.[Medline]
9. Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Dávila-Román VG. The Ross procedure: long-term clinical and echocardiographic follow-up Ann Thorac Surg 2004;78:773-781.[Abstract/Free Full Text]
10. Luciani GB, Favaro A, Casali G, Santini F, Mazzucco A. Ross operation in the young: a ten-year experience Ann Thorac Surg 2005;80:2271-2277.[Abstract/Free Full Text]
11. Tantengco MVT, Humes RA, Clapp SK, et al. Aortic root dilation after the Ross procedure Am J Cardiol 1999;83:915-920.[Medline]
12. David TE, Omran A, Ivanov J, et al. Dilation of the pulmonary autograft after the Ross procedure J Thorac Cardiovasc Surg 2000;119:210-220.[Abstract/Free Full Text]
13. Simon-Kupilik N, Bialy J, Moidl R, et al. Dilatation of the autograft root after the Ross operation Eur J Cardiothorac Surg 2002;21:470-473.[Abstract/Free Full Text]
14. Settepani F, Kaya A, Morshuis WJ, Schepens MA, Heijmen RH, Dossche KM. The Ross operation: an evaluation of a single institution's experience Ann Thorac Surg 2005;79:499-504.[Abstract/Free Full Text]
15. Chiappini B, Absil B, Rubay J, et al. The Ross procedure: clinical and echocardiographic follow-up in 219 consecutive patients Ann Thorac Surg 2007;83:1285-1289.[Abstract/Free Full Text]
16. Pasquali S, 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]
17. Brown JW, Ruzmetov M, Rodefeld, MD, Mahomed Y, Turrentine MW. Incidence and risk factors for pulmonary autograft dilation after Ross aortic valve replacement Ann Thorac Surg 2007;83:1781-1789.[Abstract/Free Full Text]

This article has been cited by other articles:

				L. Niclauss, D. Delay, M. Hurni, and L. K. von Segesser Experience and intermediate-term results using the Contegra(R) heterograft for right ventricular outflow reconstruction in adults Interactive CardioVascular and Thoracic Surgery, October 1, 2009; 9(4): 667 - 671. [Abstract] [Full Text] [PDF]

				A. Vahanian, B. Iung, L. Piérard, R. Dion, and J. Pepper CHAPTER 21 Valvular Heart Disease ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]

				M. A.A.M. Schepens Invited Commentary Ann. Thorac. Surg., August 1, 2008; 86(2): 489 - 490. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alessandro Frigiola Marco Ranucci Alessandro Giamberti Raul Abella Marisa Di Donato Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Frigiola, A. Articles by Di Donato, M. Search for Related Content PubMed PubMed Citation Articles by Frigiola, A. Articles by Di Donato, M. Related Collections Valve disease Related Article