Ross Root Dilation in Adult Patients: Is Preoperative Aortic Insufficiency Associated With Increased Late Autograft Reoperation?

Abstract

The Ross aortic valve replacement (AVR) offers excellent hemodynamic and clinical outcomes in most patients undergoing aortic root replacement. Because of ongoing debate regarding the durability of this procedure, long-term follow-up in a large adult Ross experience might be of interest. Between 1994 and 2010, 230 adult patients underwent modified Ross root procedures. Mean age was 42.4±12.1 years (range, 20 to 68 years), 62% were male. Fifty-six patients (24%) had undergone one or more prior aortic valve interventions. Concomitant procedures were performed in 126 patients (55%), including 90 ascending aortic procedures. Presenting pathology was aortic insufficiency in 114 (50%) and aortic stenosis in 116 (50%). Hospital mortality or within 30 days was 2 of 230 patients (0.9%). During follow-up (mean, 7.8 years), 12 more patients died. At 15 years, survival was 94%, and freedom from autograft and allograft reoperation was 91% and 98%, respectively. Reoperation was required for 23 patients. Eighteen patients required reoperation on the autograft root; 11 of 18 (61%) had preoperative aortic insufficiency as their predominate aortic valve lesion. Freedom from autograft reoperation was not significantly different for patients with preoperative aortic insufficiency (87%) compared with patients who had aortic stenosis (94%; p=0.15). On multivariable analysis, no risk factors were significant for reoperation except for surgery before 2000 (p<0.0001) and previous AVR (p=0.05). Preoperative aortic regurgitation was not a significant risk factor for late autograft reoperation in adults. The Ross AVR provides excellent hemodynamics and survival for adults willing to accept a small risk of reoperation as opposed to a life-long risk of thromboemboli and anticoagulation therapy as exist with mechanical aortic prostheses. Reoperation risk for Ross AVR has decreased with Ross annulus sinotubular junction reinforcement replacement of a dilated ascending aorta and postoperative hypertension management.