Reparative surgery of the pulmonary autograft: Experience with Ross reoperations

Abstract

Objective: Autograft valve and root pathology is the leading cause of Ross procedure failure. To define risk and outcome of autograft valve/root repair at reoperation, a 17-year experience was analysed. Methods: One hundred and thirty-two consecutive late survivors underwent cross-sectional clinical and echocardiographic examination on average 10.8±14.7 years (range 0.4-17) after Ross procedure. Study endpoints were hospital and late morbidity, freedom from autograft reoperation, freedom from root/valve replacement and functional outcome after valve/root repair. Results: Twenty-seven (20%) patients underwent 33 cardiac reoperations, the first on average 7.7±4.5 years (range 0.08-16.2) after Ross operation. Nineteen had undergone root replacement, 5 inclusion cylinder and 3 subcoronary grafting. Indication was root pathology in 17 (63%) patients and isolated valve in 10. Surgery consisted in valve repair/sparing in 17 patients and valve/root replacement in 10, with no hospital mortality. Freedom from any autograft valve/root reoperation was 74±5% at 15 years. No patient with valve/root replacement required second reoperation. Instead, 6/17 (35%) patients having autograft valve repair/sparing and followed for 4.2±2.9 years (range 0.3-10.8) required re-repair/AVR, while 11 present mild AI or less. Freedom from autograft valve/root replacement was 83±5% at 15 years. At multivariate analysis, predictors of reoperation were age at Ross (P = 0.002) and use of root technique (P=0.049). Failure of autograft valve repair/sparing was associated with isolated valve pathology (P=0.014) and earlier reoperation (P=0.002). Pre-repair autograft insufficiency was significant at univariate analysis only (P=0.01). Conclusions: Autograft reoperation carries negligible hospital risk. Pulmonary valve sparing or repair is feasible in half of patients with Ross failure. Concomitant root remodelling and absence of preoperative severe valve dysfunction predict successful and durable repair. © The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.