Are Mechanical Prostheses Valid Alternatives to the Ross Procedure in Young Children Under 6 Years Old?

Abstract

Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used. We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n= 84) or MP (n= 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes. Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P= .24) or 15-year transplant-free survival (94.1% vs 87.5%, P= .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P= .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P= .78] vs 6.0 [95% confidence interval, 0.6-63.1; P= .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P= .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement. Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve- and reoperation-related complications.