Ross operation in children and young adults: the Alder Hey case series

BACKGROUND: The ideal prosthesis for aortic valve replacement in children and young adults has not been found yet. In recent years there has been a renewed interest in the replacement of aortic valve with the pulmonary autograft owing to its advantages of lack of anticoagulation, potential for growth and excellent haemodynamic performance. The purpose of this study was to review our institutional experience at Alder Hey hospital with the Ross procedure in children and young adults. METHODS: From November 1996 to September 2003, 38 patients (mean age, 13.1 ± 5.7 years) underwent the Ross procedure for various aortic valve diseases using the root replacement technique. Clinical and echocardiographic follow-up was performed early (within 30 days), 3 to 6 months, and yearly after surgery. Medical records of all patients were reviewed retrospectively. RESULTS: There was 1 perioperative death. The patients were followed-up for a median interval of 36 months and up to 7 years. One patient died 3 years after surgery secondary to ventricular arrhythmia with overall mortality of 5.3%. Actuarial survival at 7 years was 94 ± 2.5% and there was 100% freedom from reoperation for autograft valve dysfunction or any other cause. Balloon dilatation was required in 2 patients for pulmonary homograft stenosis. The haemodynamics at the latest follow-up were also similar to those at the time of discharge after surgery. There was no progression in the degree of aortic regurgitation for 11 patients with trivial and 3 with mild regurgitation. CONCLUSION: Our experience demonstrates that Ross operation is an attractive option for aortic valve replacement in children and young adults. Not only can the operation be accomplished with a low operative risk but the valve function stays normal over a long period of time with minimal alteration in lifestyle and no need for repeated operations to replace the valve as a result of somatic growth of the children

The fate of the neoaortic valve and root after the modified Ross-Konno procedure

OBJECTIVES: In children with aortic valve disease associated with annular hypoplasia or complex multilevel left ventricular outflow tract obstruction, the Ross procedure, combined with a modified Konno-type aortoventriculoplasty, is advocated. We aim to examine the fate of the neoaortic apparatus and assess neoaortic valve function after the modified Ross-Konno procedure. METHODS: Forty-three patients, with a median age of 6 years, underwent the modified Ross-Konno procedure with a myectomy but without the use of a ventricular septal patch. Serial postoperative echocardiograms (n = 187) were analyzed, and regression models adjusted for repeated measures were used to model the longitudinal growth of the neoaortic annulus and root. RESULTS: There were 2 operative deaths (5%) and 1 late mortality. At 8 years, survival was 93% and freedom from autograft, homograft, and all-cause reoperation was 100%, 81%, and 72%, respectively. The median postprocedure diameter and z score were 14 mm (7-21 mm) and +1.3 (-3.0 to +6.1) for the neoaortic annulus and 21 mm (9-30 mm) and +1.6 (-1.3 to +4.1) for the neoaortic root, respectively. Serial echocardiograms showed a progressive increase in annular (+0.56 mm/year, P < .001) and root (+0.89 mm/year, P < .001) diameters but little change in annular (-0.07/year, P = .08) and root (-0.002/year, P = .96) z scores. Autograft regurgitation developed in 9 patients; however, the degree and progression of regurgitation over time were not significant (P = .22). CONCLUSIONS: After the modified Ross-Konno procedure, the neoaortic annulus and root increased in size proportionately to somatic growth. Autograft regurgitation, usually mild and stable, developed in few patients, and none required autograft reoperation. Our findings support the use of the modified Ross-Konno as the procedure of choice in children with aortic valve disease and complex left ventricular outflow tract obstructio