The Ross Operation in Adolescents

Purpose: The pulmonary autograft aortic valve replacement (Ross AVR) is the AVR of choice for children below the teenage years. Recent literature has questioned the durability of the Ross AVR in older children and young adults that present predominantly with aortic regurgitation and a dilated aortic root. At our center, the Ross AVR has been an excellent choice for most children and young and middle-aged adults. The Ross AVR is an especially good choice in young females who plan on becoming pregnant. We reviewed our experience with the Ross AVR in older children and young adults (10-20 years old) and analyzed mortality, early and late complications, and the need for reoperation and compared it to non-Ross AVR patients of the same age group during the same time period. Methods: Between 1993 and 2013, 79 children and young adults, of which 19 were female, between the age of 10 and 20, mean of 16.0 ± 2.7 years, underwent the Ross AVR. Follow-up ranged from 1 month to 20 years with a mean of 6.9 ± 5.8 years. Patients with primary and/or predominant aortic regurgitation and a dilated aortic root and/or ascending aorta at any level were called the “primarily aortic insufficiency (AI) group” (PAIG); 38 (48%) met this criteria. Because we saw some pathologic root enlargement and/or progressive aortic regurgitation in our early Ross experience (1993-2000), we modified our technique and postoperative management in 2000; 51 (65%) of 79 patients underwent the modified technique while 28 underwent our original Ross root replacement technique. The modified technique included reinforcing the aortic valve annulus and sinotubular junction and resecting or replacing the ascending aorta if it was dilated (>30 mm). Twenty-six patients during this same time period and in the same age group underwent the non-Ross AVR with a mean age of 16.5 ± 2 years. Seven of these 26 non-Ross patients were female, and 16 (62%) presented with aortic regurgitation as their primary lesion. Results: The early mortality for the Ross group and the non-Ross group was 0% and 4%, respectively. Late mortality for the Ross group was 2.5% and 0% for the non-Ross group. Of the 28 patients, 14 (50%) receiving the early Ross operation prior to 2000 have required reoperations. Only three (5.9%) of the 51 patients done after 2000 have required surgical reintervention (P <.01). In all, 11 (34%) of our Ross patients operated prior to 2000 and three (6%) after 2000 have required reintervention on their autografts. Patients in the PAIG had zero early and late deaths and a 16% rate of reoperation on the autograft compared to zero early and two late deaths and 20% rate of reoperation in patients not in the PAIG group (P = .266 and .467 respectively). The actuarial survival for the Ross group at 5 (N = 42), 10 (N = 24), and 20 (N = 1) years was 100%, 97%, and 73% respectively. Survival for the non-Ross group at 5 (N = 18), 10 (N = 8), and 20 (N = 1) years was 96%, 96%, and 96%, respectively; this difference in survival was not statistically significant (P =.90). Differences in survival without reoperation for both the groups were not statistically significant (P =.55). When comparing patients who had the newer Ross AVR technique and the non-Ross AVR patients, there was a significantly lower incidence of late aortic stenosis (AS) with a resting gradient greater than 20 mm Hg, 0% versus 53% (P <.001). Conclusion: The Ross AVR is the procedure of choice for adolescents requiring AVR who have a normal pulmonary valve. There was no difference between the outcomes in patients who were in the PAIG group compared to non-PAIG patients. There was no difference in survival without reoperation between the Ross AVR and the non-Ross AVR within the 10- to 20-year age group. The Ross AVR patients had lower incidences of nonoperative complications. The Ross AVR patients had excellent hemodynamic outcomes with a significantly lower incidence of late AS when compared to the non-Ross AVR group. Reports of 15- to 20-year survival for the Ross AVR are encouraging. Long-term follow-up is necessary in all patients with aortic valve disease regardless of the treatment modality.