ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2011;92:1156-1157. doi:10.1016/j.athoracsur.2011.03.081
© 2011 The Society of Thoracic Surgeons
This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ad J.J.C. Bogers
Johanna J.M. Takkenberg
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mokhles, M. M.
Right arrow Articles by Takkenberg, J. J. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mokhles, M. M.
Right arrow Articles by Takkenberg, J. J. M.
Related Collections
Right arrow Valve disease
Right arrowRelated Article

Correspondence

No Ross Operation for Patients With Aortic Regurgitation?

M. Mostafa Mokhles, MS, Ad J.J.C. Bogers, MD, PhD, Johanna J.M. Takkenberg, MD, PhD

Department of Cardio-thoracic Surgery, Erasmus Medical Center, Room Bd 575, PO Box 2040, 3000 CA Rotterdam, The Netherlands

(Email: m.mokhles{at}erasmusmc.nl).

To the Editor:

We read with interest the recent article by Ryan and colleagues [1] discussing the results of the Ross procedure in their adult patient population. Dr Ryan and colleagues conclude in their paper that the Ross procedure in adults provides excellent freedom from autograft failure in patients operated for aortic stenosis, but they advise readers to strongly consider other options in adults presenting with aortic insufficiency (AI). Their series and the 100% follow-up of their patients are excellent, but this report leaves us with a few outstanding questions that we would like to address.

The authors report that 4 out of 15 reoperations were for noncoronary sinus dissection. This is an incidentally reported, but potentially serious condition, and we would like to request that the authors provide more information about these patients. How were the dissections diagnosed? What was the morphology of the dissections? What did the histology reports show? This information would be valuable in increasing our understanding of noncoronary sinus dissection. In addition, we would be grateful if the authors could provide us with more details on the timing of the individual reoperations. Is there a time-dependent pattern in the reason for reoperation (eg, autograft dysfunction in the first decade and dilatation and dissection in the second decade)? This would provide clinicians with valuable information on how autograft recipients should be monitored over time (perhaps more often in the second decade than in the first decade?).

The title of the paper and the freedom from reoperation curves ( as provided in Fig 2 in the original article ) may be misleading. The title of the paper suggests that preoperative AI is associated with a higher reoperation hazard. This statement is not uniformly supported by the results of the study. Although according to the log-rank test the AI patients have lower freedom from reoperation rate, this observation is not confirmed by the Cox-regression analyses. In addition, the authors investigated the risk of preoperative AI by calculating and comparing risk estimates (odds ratios). However, this does not take into account the time dependency of the event and is inadequate. Furthermore, the upper 95% confidence interval limit of the reoperation hazard for preoperative AI is 105.9, which indicates that freedom from reoperation curves is based on very few patients, especially after 8 years of follow-up. These small sample sizes may increase the effect of assumption violations, which may result in incorrect or uninterpretable Kaplan–Meier results. In order to achieve reliable estimates of the 3 major functions (survival, probability density, hazard) and to ensure that the standard error of the survival estimate is less than 10%, the number of subjects remaining at risk in this study should be at least 13 at the time of the last survival estimate [2].

Finally, the authors' conclusion that other approaches should be considered for patients with AI should be interpreted in light of some other important issues. Even if the durability of autografts is less in patients with preoperative AI, the decision whether to perform the Ross procedures depends also on technical considerations and informed patient preferences [3].


   Acknowledgments
Top
 Acknowledgments
References
 
M. Mostafa Mokhles is funded by a Mosaic grant of the Netherlands Organisation for Scientific Research (NWO 017.006.058).


   References
Top
 Acknowledgments
 References
 

  1. Ryan WH, Prince SL, Culica D, Herbert MA. The Ross procedure performed for aortic insufficiency is associated with increased autograft reoperation Ann Thorac Surg 2011;91:64-70.[Abstract/Free Full Text]
  2. Karrison TG. Use of Irwin's restricted mean as an index for comparing survival in different treatment groups–interpretation and power considerations Control Clin Trials 1997;18:151-167.[Medline]
  3. Mokhles MM, Kortke H, Stierle U, et al. Survival comparison of the Ross procedure and mechanical valve replacement with optimal self-management anticoagulation therapy: propensity-matched cohort study Circulation 2011;123:31-38.[Abstract/Free Full Text]

Related Article

Reply
William H. Ryan and Morley A. Herbert
Ann. Thorac. Surg. 2011 92: 1157. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
E. I. Charitos, J. J. M. Takkenberg, T. Hanke, A. Gorski, C. Botha, U. Franke, A. Dodge-Khatami, J. Hoerer, R. Lange, A. Moritz, et al.
Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: An update on the German Dutch Ross Registry
J. Thorac. Cardiovasc. Surg., October 1, 2012; 144(4): 813 - 823.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ad J.J.C. Bogers
Johanna J.M. Takkenberg
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mokhles, M. M.
Right arrow Articles by Takkenberg, J. J. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mokhles, M. M.
Right arrow Articles by Takkenberg, J. J. M.
Related Collections
Right arrow Valve disease
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS