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Sections of Cardiothoracic Surgery, James W. Riley Hospital for Children and Indiana University School of Medicine, Indianapolis, Indiana
Accepted for publication May 5, 2009.
* 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-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract |
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Methods: Between June 1993 and January 2009, 212 consecutive patients (mean age, 24.8 ± 15.5 years; range, 1 month to 67 years) underwent Ross aortic valve replacement; 49% were younger than 19 years old. One hundred forty-two additional procedures were required in 101 of the 212 patients (48%) at the time of the Ross aortic valve replacement. One hundred ninety-three patients had isolated aortic valve disease, and 19 pediatric patients had more complex, multilevel left ventricular outflow tract obstruction.
Results: There were 2 early (1%) and 2 late deaths (1%), with a mean follow-up of 7.9 ± 4.2 years (range, 1 month to 15 years). Actuarial survival at 15 years was 98%. To date 28 patients (13%) have required reoperation. At 15 years, freedom from autograft sinus or ascending aortic dilatation was 79%, autograft dysfunction, 91%, autograft reoperation, 89%, and autograft replacement, 96%. Freedom from pulmonary allograft replacement was 96% at 15 years.
Conclusions: The Ross aortic valve replacement can be performed in children and adults with good midterm results. The late complications of autograft regurgitation, sinus or ascending aortic dilatation, can usually be corrected with a valve-sparing root replacement. These complications can often be prevented by (1) aggressive treatment of postoperative systemic hypertension, (2) replacement of a dilated ascending aorta at the initial Ross procedure, or (3) external fixation of the autograft annulus or sinotubular junction. The potential of late autograft insufficiency, ascending aortic and sinus dilatation, or homograft stenosis and insufficiency warrants annual follow-up.
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Introduction |
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Since 1993 when we began employing the Ross procedure at Indiana University, evolving operative and management advances have been made including techniques of autograft harvest, annular enlargement or reduction, and strategies to prevent autograft dilatation.
The purpose of this report is to evaluate our 16 year clinical experience with the Ross AVR root replacement with respect to patient survival, durability of the autograft and pulmonary allograft, and risk factors for reoperation in children and adults.
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Patients and Methods |
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Results of echocardiographic analysis of each semilunar valve, surgical or transcutaneous intervention, and long-term follow up were abstracted from our cardiology database and from personal communication with family and referring physicians.
Transthoracic M-mode, two-dimensional color mode, and Doppler echocardiograms were obtained for all patients before hospital discharge and for most patients annually. The degree of autograft and neopulmonary regurgitation was quantified as nontrivial, mild, moderate, and severe [10]. The peak velocity flow across both semilunar valves was assessed. Growth of the pulmonary autograft in children was documented by postoperative echocardiographic diameter measurements at the neoaortic annulus and compared with follow-up annular measurements at yearly intervals. Echocardiographic measurements of the pulmonary autograft included end-systolic diameters at three levels: the annulus, sinus of Valsalva, and the origin of the ascending aorta 2 cm above the sinotubular junction.
Surgical Technique
The aortic root was opened obliquely and the valve was inspected. If the native valve was not repairable, it was excised and the annulus was measured.
The main pulmonary artery was transected proximal to the bifurcation, and each leaflet was inspected. If the valve was structurally normal, the pulmonary root was harvested using low-current electrocautery. Care was taken to avoid injury to the septal perforator arteries. A 3- to 5-mm cuff of right ventricular muscle was harvested proximal to the annulus of the autograft valve. The three inflow commissures were marked with a pen.
The aortic root was dismantled by excising both coronary arteries with large buttons of aortic sinus tissue. The noncoronary sinus was excised, and the commissural posts were shortened to give the annulus a circular and less scalloped shape. If the aortic annulus was adult size (ie, 20 to 24 mm), 2-0 braided polyester sutures with 3- to 7-mm Teflon pledgets were passed sequentially through a 5-mm wide strip of Dacron (Hemashield patch; DuPont, Wilmington, DE) and through the aortic annulus from outside to inside. Once the aortic annulus was encircled, the sutures were passed through the autograft (inside to out) so that the left coronary artery would be situated into the middle of the posterior sinus of the autograft.
The everted edges of the autograft muscular cuff and the aortic annulus were closed with a 4-0 polyglycolic suture to aid in proximal suture line hemostasis. The left coronary artery was positioned in the center of the posterior sinus of the autograft once a modest portion of the sinus was excised.
The right coronary artery was commonly inserted close to a commissure at or above the sinotubular junction. Positioning the right coronary artery correctly was critical and demanded careful judgment. Some surgeons complete the distal autograft anastomosis to distend the aortic root before inserting the right coronary artery. We favor insertion before the distal aortic anastomosis because one can see the autograft valve leaflets and we believe the pulmonary allograft is more easily inserted before the distal aortic anastomosis is completed.
A pulmonary allograft 6 to 12 mm larger than the autograft was divided at the level of the ligamentum. The distal anastomosis was done first with continuous 4-0 polypropylene and the suture was tied over a Hegar dilator placed into the allograft to prevent need for placing pursestring sutures. For most older patients, the proximal anastomosis was completed with polypropylene 3-0 continuous suture, taking care posteriorly not to impale the carefully preserved septal perforators.
The distal aortic anastomosis was completed with a 5-mm Dacron strip incorporated into the anastomosis to prevent postoperative dilatation. If the ascending aortic diameter was greater than 35 mm, we would replace the aorta with a Hemashield graft equal to or 2 mm smaller than the autograft annulus. When a Ross-Konno procedure was performed (n = 16), the autograft was harvested with a 10- to 15-mm extension of right ventricular free wall for patch enlargement of the septal incision.
Annular enlargement was performed if the diameter of the aortic valve annulus was more than 4 mm smaller than the pulmonary valve annulus. An incision was made through the aortic valve annulus to the left of the right coronary artery and advanced 1 to 2 cm onto the muscular septum in 16 patients. One patient had a Nicks' procedure. The annulus was enlarged from 10.2 ± 3.2 mm (range, 3 to 14 mm) to 20 ± 3 mm (range, 16 to 24 mm; p < 0.001).
Annular reduction was indicated when the aortic valve annulus was more than 4 mm larger than the pulmonary valve annulus. The annulus was reduced from 35 ± 8 mm (range, 24 to 52 mm) to 25 ± 2.5 mm (range, 20 to 32 mm; p < 0.001) in 36 patients (17%). Annular reduction was performed using a 5-mm wide Dacron strip (DuPont) placed circumferentially around the aortic annulus and taking smaller bites of the Dacron and wider bites of the aortic annulus, thus, pleating the aortic annulus 2 to 3 mm per mattress suture along the left and noncoronary portions of the aortic annulus. The annular reduction was measured by placing an appropriately sized Hegar dilator through the aortic annulus.
The proximal autograft suture line was fixed with a Dacron strip as described above routinely after 2000 when the aortic annulus was 20 to 24 mm and annular growth was not desired.
The right ventricular outflow tract (RVOT) was constructed with pulmonary homograft (cryopreserved, n = 181; decellularized, n = 24; CryoLife, Inc, Marrietta, GA) oversized 6 to 14 mm larger than the autograft. Seven patients received a bovine jugular vein conduit (Contegra, 12 to 16 mm; Medtronic, Inc, Minneapolis, MN).
Thirty-nine patients with ascending aortic aneurysms or significant dilatation (>35 mm) required ascending aortic root replacement with a synthetic tube graft.
Concurrent procedures in patients with multilevel left ventricular outflow tract (LVOT) obstruction included subaortic membrane resection or myomectomy (n = 11), apical aortic conduit division (n = 3), arch augmentation (n = 3), mitral valve replacement or repair (n = 1), and ventricular septal defect closure (n = 5).
Early death was defined as death in the hospital or within 30 days of discharge, and all other deaths were considered late. Patient survival started at the time of the Ross AVR and ended at the time of death or at last follow-up. Valve-related events were defined according to the guidelines for reporting morbidity and mortality after cardiac valvular operations [11]. Follow-up was complete within 1 year of the study's closure in 69% of the patients and within 2 years of closure in 95% of the patients. The follow-up represents a total of 1,670 patient-years. Mean follow-up was 7.9 ± 4.2 years (range, 0 to 15 years).
Statistical Analysis
Statistical software SPSS for Windows, version 10 (SPSS Inc, Chicago, IL) was used for data analysis. Categoric variables are reported as absolute numbers and percentages. Continuous variables are expressed as mean ± standard deviation or as the median value and the range. Comparison of continuous variables was performed using the two-tailed Student's t test for paired data, and comparison of discrete variables was done with the Fisher's exact test. For all tests, a probability value of less than 0.05 was considered significant. Actuarial survival and freedom from reoperation and survival were determined using the Kaplan-Meier method.
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Results |
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Five patients required extracorporeal membrane oxygenation for postoperative low cardiac output. One patient expired during weaning (stated above), and a second patient with anticardiolipin antibody required orthotopic transplantation on postoperative day 5. This patient and the remaining 3 patients who were successfully weaned from extracorporeal membrane oxygenation are all long-term survivals. Additional morbidity included reexploration for bleeding in 2 patients and complete heart block requiring permanent pacemaker insertion in 2 patients undergoing a Ross-Konno procedure.
Survival
Fifteen-year survival is 98.1% ± 0.6%. Overall survival at 15 years was significantly better for patients older than 1 year of age when compared with patients younger than 1 year of age (99.5% versus 57%; p = 0.001), but did not differ for children compared with adult patients (97% versus 99%; p = 0.52); or for patients undergoing Ross AVR after 2000 compared with patients undergoing Ross AVR before 2000 (99% versus 98%; p = 0.48).
Reoperation
Twenty-eight patients (13%) underwent reoperation at a median interval of 7 years (mean, 6.8 ± 2.9 years; range, 9 months to 13 years). Among these patients, 16 (57%) required autograft reinterventions, 7 (25%) required simultaneous reinterventions on the autograft and the pulmonary allograft, and 4 (14%) required isolated allograft replacement. The remaining patient underwent repair of a left ventricular pseudoaneurysm below the Ross valve.
Progressive dilatation of the neoaortic root was the main cause for autograft reoperation. Nonmutually exclusive indications for autograft reoperation were (1) sinotubular junction, sinus, or ascending aortic diameter greater than 50 mm; (2) moderate or greater aortic insufficiency with a progressive increase in left ventricular end-systolic dimension; and (3) all patients with aortic insufficiency more than moderate. A valve-sparing root replacement with resection of the ascending aorta aneurysm was performed in 15 patients (10 patients had isolated aortic root dilatation and 5 patients had concomitant pulmonary valve replacement). Early in our experience, aortic root replacement with a composite mechanical valve and graft was performed in 8 patients before we became comfortable with valve-sparing root replacement or because the patient wanted to avoid a possible second reoperation.
Among the 11 patients (7 concomitant; 4 isolated) reoperated on for pulmonary allograft stenosis (10 patients) or regurgitation (1 patient), a second nondecellularized pulmonary allograft was inserted in 4, a porcine valve in 3, a bovine pericardial valve in 2, and a Gore-Tex monocusp valve in 2 patients.
Indications for pulmonary prosthesis replacement included a right ventricular to left ventricular end-diastolic volume ratio greater than 1.8/1.0 derived with magnetic resonance imaging, or a right ventricular to pulmonary arterial pressure gradient greater than 40 mm Hg with or without moderate to severe pulmonary insufficiency.
Overall freedom from reoperation at 15 years was 87% and was not significantly improved for patients older than 18 years when compared with patients younger than 18 years of age at the time of the Ross AVR (older, 86 of 105 patients, 82%, versus younger, 96 of 105 patients, 91%; p = 0.07) but was significantly better for all patients undergoing the Ross AVR after 2000 compared with patients undergoing Ross AVR before 2000 (before 2000, 102 of 105 patients, 98%, versus after 2000, 89 of 105, 85%; p = 0.001).
Freedom from reoperation for autograft dysfunction at 15 years was 89%. Freedom from autograft reoperation was significantly better for patients undergoing Ross AVR after 2000 compared with patients undergoing Ross AVR before 2000 (99% versus 87%; p = 0.001) but did not differ for patients older than 18 years of age compared with patients younger than 18 years of age (92% versus 85%; p = 0.13). Freedom from autograft replacement at 15 years was 96%.
Freedom from pulmonary allograft reoperation for structural failure at 15 years was 95%. Freedom from allograft reoperation for structural failure was significantly better for patients older than 18 years of age compared with patients younger than 18 years of age (98% versus 91%; p = 0.03) and in patients undergoing AVR after 2000 compared with patients undergoing Ross AVR before 2000 (100% versus 91%; p = 0.001).
Postoperative Transesophageal Echocardiography
A transesophageal echocardiogram was routinely performed in the operating room after Ross AVR. Trivial neoaortic insufficiency or less was observed in 181 patients (86%), whereas 29 patients (14%) had mild aortic insufficiency. No patient had significant LVOT obstruction. The valved conduit used to construct the RVOT was competent in 187 patients (90%) and showed mild regurgitation in 23 patients (10%). No patient had important flow acceleration (obstruction) across the RVOT reconstruction.
Follow-Up and Echocardiography
Follow-up was 95% complete (200 of 210 patients). The mean follow-up time was 7.9 ± 4.2 years (median, 8 years; range, 1 month to 15 years). During the last follow-up, 98% of the patients were in New York Heart Association functional class I or II. All surviving patients are doing well and have not required medications after the third postoperative month.
Forty-five patients (21%; 28 pediatric patients and 17 adult patients) have aortic root dilatation (>40 mm). Only 21 (11%) have met the criteria for elective valve-sparing or prosthetic root replacement (50 mm). Aortic root dilation has occurred during 6.4 ± 2.9 years (range, 2 to 13 years). Freedom from autograft sinus or ascending aortic dilatation greater than 40 mm at 15 years was 79%. Freedom from autograft sinus or ascending aortic dilatation was significantly better for patients older than 18 years of age compared with patients younger than 18 years of age (85% versus 72%; p = 0.003) and in patients undergoing Ross AVR after 2000 compared with patients undergoing Ross AVR before 2000 (93% versus 67%; p < 0.001). Freedom from autograft dysfunction (defined as >2+ aortic regurgitation) was 91%.
The most recent follow-up echocardiogram on all survivors revealed 2.4% of the patients (n = 5) had moderate aortic regurgitation, 3% (n = 6) with moderate pulmonary regurgitation, and 5% of the patients (n = 10) had moderate to severe pulmonary stenosis. All are being observed yearly. The peak LVOT pressure gradient was 15.6 ± 11.6 mm Hg (range, 0 to 55 mm Hg) and the peak neopulmonary pressure gradient was 20.5 ± 11.8 mm Hg (range, 0 to 61 mm Hg). Patients with moderate aortic regurgitation and pulmonary stenosis will likely require reoperation in the near future.
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Comment |
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The Ross AVR is now considered a better alternative to mechanical, xenograft, and homograft AVR in the treatment of aortic valve disease in both children and young adults [15, 16]. As in other centers, we have expanded the indications for Ross AVR to patients with more complex LVOT disease, including active bacterial endocarditis, complex multilevel LVOT obstruction, and patients with associated aneurysmal dilatation of the ascending aorta [16, 17]. Despite the inclusion of higher risk patients, the procedure can be performed with a low overall mortality (1% for this series). Patient selection criteria have broadened recently to include younger children and adults older than 55 years of age. Contraindications to the Ross AVR include prior cardiac surgery jeopardizing the integrity of the pulmonary autograft; recognized connective tissue disease including Marfan syndrome, Ehlers-Danlos syndrome, and osteogenesis imperfecta, and chronic inflammatory disorders such as rheumatic heart disease and rheumatoid arthritis with pulmonary valve involvement.
Despite initial concerns, results of several large-scale clinical studies indicated that the Ross procedure is safe and has favorable short-term [15, 18] and long-term results [19]. The present study is in agreement with these earlier reports and has follow-up to 15 years. The hospital mortality in our series was 1% and comparable with the 4% to 5% reported in the International Ross Registry [20]. All 4 deaths in this series (2 early and 2 late) were in patients with complex associated problems. Three infants who died had undergone a Ross-Konno procedure and the neonate who died early required additional procedures (atrial and ventricular septal defect closure, and extensive patch aortoplasty). None died a cardiac death. The only early adult death was in a patient who required coronary artery bypass grafting and had advanced preoperative liver disease; this patient had a postoperative cardiac arrest and died of multisystem organ failure 4 days postoperatively. The overall survival rate at 15 years is 98%. In addition, we have not observed any thromboembolic events or postoperative endocarditis.
Our experience raises several technical and patient selection concerns. Autograft root and ascending aortic dilation with autograft insufficiency was the most common cause of autograft reoperation. The most common cause of autograft insufficiency was dilation of the autograft annulus and sinotubular junction, particularly in patients in whom aortic insufficiency was the primary lesion. Early in our experience, we did not routinely fix the aortic annulus or sinotubular junction with a Dacron strip unless the aortic annulus was dilated and needed reduction. We presently use aortic annulus and sinotubular junction fixation with synthetic material in all older adolescents and adults whose aortic annulus (Z score) is greater than +1. We reduce the aortic annulus if it is dilated. Elkins and colleagues [19] describe that the only independent predictors of development of moderately severe or severe autograft insufficiency were increasing age at the time of the operation, autograft insufficiency at completion of the operation, and increasing follow-up time.
Careful inspection of the pulmonary valve is essential before proceeding with a Ross AVR. Use of a pulmonary valve with major abnormalities will likely accelerate failure. Since early in our surgical experience, the Ross AVR was undertaken in patients with minor structural defects of the native pulmonary valve (ie, bicuspid or quadricuspid pulmonary valve, small fenestrations away from the commissures, or discrepancy in leaflet size) and no significant pulmonary regurgitation. None of these patients have required autograft reintervention.
Our experience supports the use of the Ross AVR in the management of patients with aortic valve endocarditis. Eighteen patients had endocarditis that led to AVR, and in 9 patients it was active. In patients with active endocarditis, appropriate antibiotic therapy was completed after surgical intervention, and no late endocarditis has developed.
Recent concern centers on autograft failure caused by autograft root dilation, especially in patients with a bicuspid aortic valve [7, 9, 21]. Several authors have identified significant increases in autograft sinus and root diameters [9, 21], whereas others have shown limited dilation after the first postoperative year [22]. Reporting a small but persistent increase in root dimensions and neoaortic root regurgitation with time, we have anticipated that more reoperations would be necessary in the upcoming years [23, 24]. Late root dilation has also been observed by other studies [7, 8, 25]. Since 2000, we have modified our technique to routinely fix the autograft annulus and sinotubular junction with a Dacron strip or replace a dilated aorta if it is larger than 35 mm. We also aggressively treat postoperative systemic hypertension to prevent sinus dilatation.
If autograft root dilatation occurs, the valve-sparing root replacement techniques proposed by Yacoub and David and used by our group in 15 patients allows the autograft to be salvaged [6, 21]. We use valve-sparing technique when the autograft sinuses or ascending aorta reach 50 mm regardless of the absence of autograft regurgitation.
Although the exact causes of autograft root dilatation still have to be determined, several factors may play a role. One of those factors is the root replacement technique. This technique requires surgical expertise, which varies among surgeons [19, 21, 23]. We insert the autograft at the annulus level in a nonscalloped manner, use a two-layer technique, and keep the autograft root as short as possible.
When the autograft is inserted as an inclusion cylinder, the native aorta is supporting the pulmonary autograft and may thus prevent it from dilatation. However, the number of autografts implanted as an inclusion cylinder is small according to published literature, and their follow-up duration is limited, so any speculations should be interpreted with caution [25, 26].
Another factor that may play a role in autograft dilatation is the presence of bicuspid valve disease [19, 21, 22, 25, 27, 28]. However, in a recent autograft explant study no association was observed between bicuspid valve disease and histologic changes in explanted pulmonary autografts [29]. A bicuspid valve is not a contraindication to a Ross AVR. In fact 80% of the patients in this series had a bicuspid valve.
Patients who dilate their ascending aorta (>40 mm) are at increased risk for late development of progressive ascending aorta dilatation and autograft regurgitation. Since 2000, we replace the dilated ascending aorta with a Dacron graft to support the sinotubular junction of the autograft. We do not believe that reverting to a subcoronary or inclusion cylinder would be useful in this subset. The technique of Slater and associates [30] of placing a Dacron sleeve around the autograft was recently introduced to address this concern, and we have used this modification in 1 patient who had poorly controlled systemic hypertension. Annulus reduction and fixation should be considered in all older patients with predominant aortic insufficiency and any older patient who has an aortic annular diameter more than 4 mm greater than the pulmonary annulus diameter. In the last several years we have adopted the recommendation of Elkins and colleagues [19] to replace the ascending aorta if it is significantly dilated greater than 35 mm. We also routinely treat systemic hypertension aggressively postoperatively with β-blockers and angiotensin-converting enzyme inhibitors to prevent autograft dilatation and subsequent regurgitation.
The long-term function of right-sided pulmonary allografts in Ross patients is superior to their function as an extracardiac conduits used for congenital right heart defects [31]. Alternatives to pulmonary allografts in the RVOT position in patients undergoing a Ross procedure have been tried. These include stented or stentless porcine valves, Gore-Tex monocusp valves, and bovine jugular venous valve conduits [32, 33]. However, none of those trials have proven superiority to the homograft except in young infants where allograft durability is poor (personal experience). Pulmonary allografts continue to be our preferred RVOT replacement in all but small infants where bovine jugular venous valved conduits are favored.
Pulmonary allograft regurgitation requiring replacement has been rare in our experience, with only 1 infant requiring RVOT valve replacement. Allograft stenosis in most large series is 5% to 10% with infants having the highest rate of up to 25% at 4 years [34]. Twelve patients have required reoperation for allograft dysfunction in our series (5%). Another 10 patients (5%) have a significant gradient and will likely require replacement. This low incidence of allograft obstruction in secondary to the ability to oversize the homograft by as much as 10 mm in diameter at the time of the Ross AVR. Morales and colleagues [16] described their experience with RVOT reconstruction in Ross patients (without oversizing the pulmonary allograft): freedom from RVOT replacement in their series was 76% at 5 years.
The success of the Ross AVR has made it an essential part of therapy for diseased aortic valves in adults and children at our institution. The incidence of significant autograft aneurysmal dilation and autograft valve insufficiency has decreased with modifications used since 2000. When and if autograft dilatation occurs; salvage of the Ross valve is nearly always possible using a valve-sparing technique. Concerns about the autograft and homograft warrant annual follow-up through the intermediate and late term. Modifications of the root replacement Ross AVR, which includes annular and sinotubular reduction or stabilization, and concomitant replacement of the dilated ascending aorta and postoperative hypertension prevention should further reduce the already small incidence of late Ross AVR postoperative problems. Oversizing pulmonary allografts or using alternative RVOT conduits may further reduce the small incidence of late RVOT problems seen with the Ross AVR. Further long-term follow-up will determine the true durability of the Ross AVR for two to five decades.
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Discussion |
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Now, coming to the midterm results, I think we are now more comfortable with valve-sparing operations, and I would just like you to detail, if you would, exactly when you employ that particular procedure to a patient who presents with aortic insufficiency and a dilated ascending aorta, and perhaps very briefly the technical aspects of how you do that operation.
Again, I appreciate the opportunity of commenting on your paper and I think it was excellent.
DR BROWN: Thank you, Jim. I will try to answer briefly. Of the valve-sparing root replacements, we use the David technique in about half and the Yacoub technique in about half. If it is only the noncoronary sinus that is dilated, we don't disturb the right and left coronary sinuses, we just replace the noncoronary sinus, and we would call that a Yacoub, but the others have had valve-sparing root replacements. And we use as our indication the same indications you would use for someone with Marfan's syndrome. If you get up to that 5-cm-diameter mark, even though the valve is not leaking, we think it is time to go ahead and move ahead, because there is an incidence that those will continue to dilate. And so we think we might as well get on with it.
DR EDWARD D. VERRIER (Seattle, WA): I would like to take of the argument, because this is an operation that there was tremendous excitement for a number of years and then it almost dropped off the scene except in a few committed, dedicated centers like Oklahoma and yourself. I could suggest that the natural history of the operation is much more what the registry has shown in the hands of surgeons if the Ross is expanded outside of those centers. With the registry showing a 4% overall mortality in relatively young patients, not your less than 1% mortality, if the Ross becomes more generalized it may be actually fairly dangerous.
The second question I have is that we know that there is a lot of data now in congenital bicuspid valves that there are single or maybe more nucleotide deficiencies in the aortic root. So if you are doing this in 75% of your patients that have congenitally bicuspid valves, don't you think in the long run you are going to run the risk of a lot of aortic root dilatation based on the aortic pathology and that you are just seeing the tip of an iceberg that may develop as those roots dilate based on the aortic wall pathology and not the valve pathology?
DR BROWN: Well, I think your points are well taken. I think you really ought to compare the Ross with what else is out there. I don't know whether you can go back to the slides and show my first discussion slide, if you can pull that up, but let me go ahead and answer the other questions.
The root dilatation seems to occur in only 20% of patients who have bicuspid aortic valves. We can't select them ahead of time about who has that genetic propensity for root dilatation, but in our experience it seems like at last follow-up, 80% of our patients have sinus diameters of 40 or less. So it is only that 20% who go ahead to dilate. If we could pick those out ahead of time, obviously we would prospectively deal with them differently. But if mechanical valves and if bioprosthetic valves were perfect and were durable, I don't think we would have an argument here, but they are not.
This is the discussion slide that I hope that you can see. This is a slide loaned to me by Cary Akins, and the mechanical valves are in blue and the bioprosthetic valves are in red and the bars, and this is what happens to these two valves 12 years if they are followed longitudinally. And you can see that the mortality is considerable, 50%; if you look at the major bleeding problems with mechanical valves, it is 40%; and you can see thromboembolism, endocarditis, and the need for reoperation being what it is. This is what the Ross procedure is comparing to. And I realize this slide is slightly out of date, it is 10 years old; however, these problems with bioprosthetic valves and mechanical valves still exist. So I think to deprive particularly a young individual, a young female, or a young athlete, and subject them to a valve that is hemodynamically not as good but doesn't have the durability and other aspects would be a mistake.
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This article has been cited by other articles:
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  F. Juthier, A. Vincentelli, C. Pincon, C. Banfi, P. V. Ennezat, S. Marechaux, and A. Prat Reoperation After the Ross Procedure: Incidence, Management, and Survival Ann. Thorac. Surg., February 1, 2012; 93(2): 598 - 605. [Abstract] [Full Text] [PDF]
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J. W. Brown, J. W. Fehrenbacher, M. Ruzmetov, A. Shahriari, J. Miller, and M. W. Turrentine Ross Root Dilation in Adult Patients: Is Preoperative Aortic Insufficiency Associated With Increased Late Autograft Reoperation? Ann. Thorac. Surg., July 1, 2011; 92(1): 74 - 81. [Abstract] [Full Text] [PDF]
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 J. W. Brown, M. Ruzmetov, A. P. Shahriari, M. D. Rodefeld, Y. Mahomed, and M. W. Turrentine Modification of the Ross aortic valve replacement to prevent late autograft dilatation Eur J Cardiothorac Surg, May 1, 2010; 37(5): 1002 - 1007. [Abstract] [Full Text] [PDF]
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