Ann Thorac Surg 2008;86:489-490. doi:10.1016/j.athoracsur.2008.04.089
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Marc A.A.M. Schepens, MD, PhD
Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein, 3435 CM, the Netherlands
(Email: m.schepens{at}antonius.net).
The article of Frigiola and colleagues [1] describes the immediate and long-term follow-up after the Ross procedure in 110 adult patients. The emphasis of the analysis lies on the risk factors for reoperation on the pulmonary autograft. The authors also study the behavior of the neoaortic root and explore the incidence of its dilatation over time. At first glance, the surgical results seem to be excellent: 0% in-hospital mortality and a very low complication rate. Therefore, I fully agree with the authors that this procedure can be performed safely. From a surgical perspective, the Ross procedure is a fascinating, intriguing, and complex intervention. But what about the long-term results in adults: Are they so satisfying? Are patients really served with an operation that, so to speak, solves a single-valve problem by creating a double-valve problem in the long run? How do we deal with an approximately 13% severe aortic valve incompetence, 7% reoperations for pulmonary autograft dilatation, and 3% reoperations for homograft failure after a mean follow-up period of only 7 years? Do we accept without hesitation a progressive dilatation of 0.26 cm/year at the level of the sinuses of Valsalva and even 0.49 cm/year at the level of the sinotubular junction? After a period of 12 years follow-up, 50% of the operated patients have a root that is dilated to 40 mm. Other series [2–4] have shown similar or somewhat better results. We should not salve our conscience by the fact that at the level of the aortic annulus everything remains stable because the authors themselves point out that the reason for reoperation is the progressive dilatation of the neoaortic root (ie, sinuses and sinotubular junction), not the annular dilatation. The supporters of the Ross procedure in adults certainly will argue that mechanical valves have a high morbidity related to the anticoagulation. That is why they advocate the Ross procedure. Are these people not aware of the excellent results of mechanical valve replacement with low-dose anticoagulation with very few thromboembolic and bleeding events? Besides that, patients who underwent a Ross procedure are not free from developing endocarditis and thromboembolic events at all [2, 4]. Quality of life after mechanical valve replacement is satisfactory. Subsequently what is the sense of developing a double-valve problem when initially there is only a single-valve one? Are we serving our patients by putting them at risk of another one or two interventions? Or are we aiming at maintaining our surgical practices by falsely persuading our patients to accept an operation of which we are sure that patients will need difficult interventions in the future again?
Apparently the sting is in the tail... In their last sentence, the authors state the magnitude of this event (ie, the reoperation on the pulmonary autograft) will be better defined in another 15 to 20 years. Other groups [2–4] have also made this remark. My bet is that nearly 100% of the patients will be reoperated on either the left side or the right side, or both. This will automatically at least partially solve the controversy of the Ross procedure in adults.
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References
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- Frigiola A, Ranucci M, Carlucci C, et al. The Ross procedure in adults: long-term follow-up and echocardiographic changes leading to pulmonary autograft reoperation Ann Thorac Surg 2008;86:482-490.[Abstract/Free Full Text]
- 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]
- Yacoub MH, Klieverik LM, Melina G, et al. An evaluation of the Ross operation in adults J Heart Valve Dis 2006;15:531-539.[Medline]
- Sievers HH, Hanke T, Stierle U, et al. A critical reappraisal of the Ross operation. Renaissance of the subcoronary implantation technique?. Circ 2006;114:I-504-I-511.[Medline]
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