Right Ventricular Outflow Tract Reconstruction in Ross Patients: Does the Homograft Fare Better?

Abstract

Background: In the Ross aortic valve replacement (AVR) procedure, the right ventricular outflow tract (RVOT) conduit is inserted in an orthotopic position. In complex congenital RVOT obstruction, the right ventricular-pulmonary artery (RV-PA) conduit is placed in a more heterotopic position. We hypothesized that durability of homograft RVOT reconstruction in the Ross AVR is improved secondary to orthotopic positioning and the ability to oversize the RV-PA homograft conduit in the Ross AVR. Methods: Between June 1993 and May 2007, 183 consecutive patients (mean age, 23.3 ± 15.2; median, 22; range, 1 month to 61 years) underwent Ross AVR with RVOT reconstruction using a cryopreserved pulmonary homograft (n = 156), decellularized pulmonary homograft (n = 22), and bovine jugular vein conduit (n = 5). Results: Three patients died (2 early, 1 late; mean follow-up, 5.7 ± 3.3 years). Twenty-four patients (13%) had a peak systolic RVOT gradient exceeding 20 mm Hg, 5 (3%) had a gradient exceeding 40 mm Hg, and 7 (4%) had more than 2+ RVOT insufficiency. Eight patients (4%) underwent conduit replacement for RV dysfunction. Freedom from RVOT reoperation at 10 years is 96%. Freedom from RV failure and dysfunction are 98% and 96% at 5 years and 96% and 93% at 10 years, respectively. Independent predictors of pulmonary homograft RV-PA conduit dysfunction are smaller (< 14 mm) RVOT conduit size (p = 0.03) and follow-up exceeding 5 years (p = 0.05). Conclusions: Stenosis and regurgitation of the RV-PA conduit in adults and children following Ross AVR is infrequent. The most logical reasons for the superior performance of the homograft in Ross patients are: (1) orthotopic positioning, (2) older age of implant, and (3) the ability to significantly oversize the homograft in Ross patients. © 2008 The Society of Thoracic Surgeons.