Ross Procedure Research Articles

Aortic valve replacement in non-elderly: the gap between reality, guidelines and evidence.

There are several treatment options for non-elderly adults (18-60 years) in need of aortic valve replacement (AVR): a mechanical or biological substitute, a homograft, the Ross procedure or nowadays even transcatheter aortic valve replacement. This study evaluated the current opinions and practices of cardiac surgeons and cardiologists concerning AVR strategies in this patient group. A 43-item online survey was sent out to several scientific organizations, individual cardiac surgeons, cardiologists and residents/fellows worldwide. Two hundred twenty-two physicians from 33 different countries answered the survey. The UK (24%), Belgium (23%) and North America (22%) are best represented. A mechanical valve is the most frequently used substitute in non-elderly. With increasing patient age, the popularity of a biological valve increases. Transcatheter aortic valve replacement and the Ross procedure are each used in <10% of this cohort. Only 12% of the cardiac surgeons has experience with the Ross surgery. In 23%, the patient seems not to be involved in the decision on the type of valve substitute. The preferred surgical treatment for non-elderly patients in need of AVR differs widely. To enable a shared decision-making process including patient preferences, there is more need for collaboration between cardiac departments, as well as education and scientific research about patient-centred outcomes of the different AVR techniques.

Outcomes of neo-aortic valve and root surgery late after arterial switch operation

BackgroundNeo-aortic root dilatation and valve regurgitation are emerging problems late after arterial switch operation (ASO). We sought to evaluate the prevalence and outcomes of neo-aortic root or valve reoperation after ASO. MethodsAll patients with biventricular circulation who underwent an ASO between 1983 and 2015 were included at a single institution. ResultsIn our cohort of 782 late ASO survivors, the median duration of follow-up was 18.1 years (interquartile range [IQR], 11.3-25.6 years). During follow-up, 47 patients (6.0%) underwent 60 reoperations on the neo-aortic valve/root. The first neo-aortic valve/root reoperation occurred at a median of 15.2 years (IQR, 7.8-18.4 years) after ASO. Operations included mechanical Bentall (31.9%; n = 15), aortic valve repair (25.5%; n = 12), mechanical aortic valve replacement (AVR) (21.3%; n = 10), valve-sparing root replacement (19.1%; n = 9), and the Ross procedure (2.1%; n = 1). There was 1 late death (2.1%). Multivariable predictors of neo-aortic valve/root reoperation were bicuspid valve (hazard ratio [HR], 4.8; 95% confidence interval [CI], 2.1-10.7; P < .001), Taussig-Bing anomaly (HR, 3.0; 95% CI, 1.2-7.4; P < .02), previous pulmonary artery band (HR, 2.8; 95% CI, 1.2-6.3; P < .01) and left ventricular outflow tract obstruction before ASO (HR, 2.4; 95% CI, 1.0-5.8; P < .04). Freedom from neo-aortic valve or root reoperation was 98.0% (95% CI, 96.7%-98.8%) at 10 years, 93.3% (95% CI, 90.8%-95.2%) at 20 years, and 88.5% (95% CI, 84.1%-91.8%) at 30 years after ASO. Among the 47 patients who underwent neo-aortic reoperation, freedom from AVR was 82.3% (95% CI, 67.7%-90.7%) at 10 years, 58.0% (95% CI, 41.8%-71.2%) at 20 years, and 43.2% (95% CI, 27.0%-58.3%) at 25 years after ASO. ConclusionsThe need for neo-aortic valve or root reoperation surpasses 10% by 30 years post-ASO. Evolving understanding of the mechanisms of neo-aortic valve insufficiency and techniques of neo-aortic valve repair may decrease the need for AVR.

Hemodynamics and diastolic function after native aortic valve preserving vs replacing surgery.

Background Alterations in left ventricular (LV) diastolic function following native tissue-preserving aortic valve (AV) procedures have not been systematically investigated. Furthermore, no comparisons have been made between these changes and those observed after prosthetic AV replacement. Methods From October 2017 to August 2020, 74 patients aged <65 years were referred to our institution for elective AV surgery. Preoperative and postoperative (i.e., discharge, 3-months and 1-year follow-up) transthoracic echocardiography was analyzed. Results Native tissue-preserving surgery was performed in 55 patients (AV repair: n=42, Ross procedure: n=13). The remaining 19 patients underwent prosthetic AV replacement. Preoperatively and at discharge, transvalvular hemodynamics and LV diastolic function were comparable in both groups. At 1-year follow-up, native valve patients showed significantly lower mean transvalvular gradients (7±5 vs. 9±3 mmHg,p=0.046) and peak velocity (1.74±0.51 vs. 2.26±0.096 m/s,p=0.004) and significantly better septal e' (9.1±2.7 vs. 7.7±2.5 cm/s,p=0.043) and lateral e' (14.7±3.1 vs. 11.7±3.7 cm/s,p=0.001). From preoperatively to 1 year postoperatively, septal and lateral e' and E/e' improved markedly after native valve preservation (septal e': +0.7 cm/s,p=0.075; lateral e': +2.3 cm/s,p<0.001; E/e': -1.5,p=0.001) but not after AV replacement (septal e': +0.2 cm/s,p=0.809; lateral e': +0.8 cm/s,p=0.574; E/e': -1.2,p=0.347). Significant negative linear correlations between postoperative transvalvular gradients and absolute changes in lateral e' and E/e' were detected during follow-up. Conclusion Preservation of native tissue in AV surgery results in superior transvalvular hemodynamics compared to prosthetic AV replacement. This may induce faster LV reverse remodeling and may explain more pronounced improvement in LV diastolic function.

Effectiveness and Safety of the Ozaki Procedure for Aortic Valve Disease in Pediatric Patients: A Systematic Review and Meta-Analysis.

The surgical treatment options for pediatric aortic valve disease are limited and have debatable long-term durability. In the current situation, the Ross procedure is considered in children for aortic valve disease(s). It is a complex surgical procedure with the risk of neo-aortic dilatation, converting a single valve disease into double valve disease, and associated with future re-interventions. Conversely, the Ozaki procedure has shown promising results in adults. Thus, the present study aimed to provide comparative evidence on the effectiveness and safety of the Ozaki versus Ross procedure for pediatric patients by performing a meta-analytic comparison of reporting outcomes. A total of 15 relevant articles were downloaded and among them, seven articles (one prospective study, five retrospective studies, and one case series) were used in the analysis. Primary outcomes such as physiologicallaminar flowpattern and hemodynamic parameters, and secondary outcomes such as hospital stays, adverse effects, mortality, and numbers of re-intervention(s) were measured in the meta-analysis. There were no significant differences in the age of patients between children who underwent the Ozaki procedure and those who underwent the Ross procedure at the time of surgeries. The Ozaki procedure is a good solution to an aortic problem(s) similar to the Ross procedure. Unlike the Ross procedure, the Ozaki procedure has restored a physiological laminar flow pattern in the short-term follow-up without the bi-valvular disease. Mean hospital stays (p = 0.048), mean follow-up (p = 0.02), adverse effects (p= 0.02), death, and numbers of re-intervention(s) of children who underwent the Ozaki procedure were fewer than those who underwent the Ross procedure. The time required for re-intervention(s) is higher for children who underwent the Ozaki procedure than those who underwent the Ross procedure. None of the procedures, including the Ozaki procedure for aortic valve disease(s), has significant effects on hemodynamic parameters and the frequent death rate of children after surgeries. Based on our analysis, we may suggest the Ozaki procedure for aortic valve disease surgery in children.

Surgical treatment of aortic root abscess: 10-year single center experience

The issue of optimal surgical scope in patients with aortic root abscess due to infective endocarditis remains open, since there are different strategies and interventional methods. In addition, the guidelines do not give preference to any particular type of surgical intervention and recommend an individual approach to each situation. The study included 25 patients with aortic root abscess due to aortic valve infective endocarditis. The most frequently performed surgical intervention in patients was the Ross procedure (n=12, 48%). Eight (32%) patients of the center underwent aortic homograft root replacement. Combined surgery was performed in 7 (28%) patients as follows: 3 (12%) patients — interventions on the mitral valve (all patients underwent mitral valve repair due to mitral valve involvement in abscess), 3 (12%) — coronary artery bypass grafting, 1 (4%) — ascending aortic replacement due to dilatation. Five- and ten-year survival after surgical treatment of patients with aortic root abscess was 86,9% and 78,6%, respectively. There was no reintervention and recurrence of infective endocarditis in the long-term period.

Surgical treatment of aortic root abscess: 10-year single center experience

The issue of optimal surgical scope in patients with aortic root abscess due to infective endocarditis remains open, since there are different strategies and interventional methods. In addition, the guidelines do not give preference to any particular type of surgical intervention and recommend an individual approach to each situation. The study included 25 patients with aortic root abscess due to aortic valve infective endocarditis. The most frequently performed surgical intervention in patients was the Ross procedure (n=12, 48%). Eight (32%) patients of the center underwent aortic homograft root replacement. Combined surgery was performed in 7 (28%) patients as follows: 3 (12%) patients — interventions on the mitral valve (all patients underwent mitral valve repair due to mitral valve involvement in abscess), 3 (12%) — coronary artery bypass grafting, 1 (4%) — ascending aortic replacement due to dilatation. Five- and ten-year survival after surgical treatment of patients with aortic root abscess was 86,9% and 78,6%, respectively. There was no reintervention and recurrence of infective endocarditis in the long-term period.

Systematic review and meta-analysis of time-to-event long-term outcomes following the Ross procedure.

The optimal aortic valve substitute for non-elderly adults remains controversial. Recently, considerable data on the Ross procedure have accumulated. This study aimed to analyze long-term outcomes following the Ross procedure from the current literature using a meta-analysis of time-to-event outcomes. A literature search was performed with MEDLINE, EMBASE, Cochrane Library, Web of Science, and Google Scholar through June 2022; studies reporting clinical outcomes of the Ross procedure beyond 20 years were included for analysis. The outcomes of interest were late survival and freedom from surgical or percutaneous reintervention of the autograft or right ventricular outflow tract (RVOT). Six studies, including 4,910 patients (3,601 males), were identified and analyzed. Survival rate at 5, 10, 15, and 20 years was 99.9%±0.1%, 97.6%±0.5%, 94.3%±0.9%, and 87.4%±1.9%. Freedom from autograft reintervention at 5, 10, 15, and 20 years was 97.7%±0.5%, 95.3%±0.7%, 91.4%±1.2%, 84.8%±2.5%. Freedom from RVOT reintervention was 99.0%±0.3%, 99.0%±0.3%, 97.5%±0.7%, 93.3%±1.8%. Freedom from any valve reintervention (either autograft or RVOT) at 5, 10, 15, and 20 years was 95.8%±0.6%, 92.6%±0.9%, 88.5%±1.2%, 80.8%±2.5%. This meta-analysis demonstrated that the Ross procedure was confirmed to provide excellent survival despite the need for reintervention of autograft or RVOT in approximately 20% of patients at 20 years.

Discussion to: Aortic valve repair versus Ross procedure in children

Discussion to: Aortic valve repair versus Ross procedure in children

New insights into the hemodynamics of pulmonary homograft patients under stress echocardiography: The contribution of pressure recovery.

The importance of pulmonary artery pressure recovery (PR) in patients with Ross procedures in whom a homograft substitutes the resected pulmonary valve, is unknown. The aim of the study was to evaluate the occurrence and extent of PR in the pulmonary artery in 65 asymptomatic patients with pulmonary homograft after Ross surgery during rest and exercise. Stress echocardiography was performed in 65 pulmonary homograft patients and 31 controls with native pulmonary valves up to 75W. Right ventricular systolic pressure (RVSP), transvalvular flow, mean pressure gradient (Pmean ), valve resistance, and RV stroke work were determined in the exercise (max. 75W) and recovery phases in increments of 25W each. Pulmonary homografts demonstrated significantly elevated Pmean compared to controls at all stages. When considering pressure recovery (absolute and relative PR at rest 3.8±1.8mm Hg, 42.6±7.2%, respectively) and transvalvular energy loss (EL; at rest 4.5±4.3mm Hg) the homograft hemodynamics reached the level of controls. In a subgroup of patients with tricuspid regurgitation, resting RVSP was the same in homograft patients and controls (21.3±6.1 vs. 20.4±6.3, p=.62), despite significant different Pmax values. Ross patients with pulmonary homograft showed systematically increased hemodynamic parameters compared to normal pulmonary valves. These differences were abolished when PR was considered for homograft patients. The equality of RVSP values at rest in both groups shows non-invasive evidence for PR in the pulmonary system after homograft implantation. Therefore, PR appears to be an important measure in calculating the actual hemodynamics in pulmonary homografts.

Preliminary experience of transcatheter pulmonary valve replacement using domestic balloon-expandable valve

Objectives: To evaluate the feasibility and preliminary clinical results of transcatheter pulmonary valve replacement (TPVR) with the domestically-produced balloon-expandable Prizvalve system. Methods: This is a prospective single-center observational study. Patients with postoperative right ventricular outflow tract (RVOT) dysfunction, who were admitted to West China Hospital of Sichuan University from September 2021 to March 2023 and deemed anatomically suitable for TPVR with balloon-expandable valve, were included. Clinical, imaging, procedural and follow-up data were analyzed. The immediate procedural results were evaluated by clinical implant success rate, which is defined as successful valve implantation with echocardiography-assessed pulmonary regurgitation<moderate and peak trans-pulmonary pressure gradient<40 mmHg (1 mmHg=0.133 kPa). Results: A total of 5 patients were included, with 4 males, aged 14 to 37 years. The initial diagnosis included Tetralogy of Fallot (2 cases), truncus arteriosus (1 case), pulmonary atresia (1 case) and subaortic stenosis (1 case, prior Ross procedure). Four patients underwent RVOT reconstruction with homograft or artificial conduit, and one patient was treated with trans-annular patch technique. The indications of TPVR included RVOT obstruction and regurgitation (3 cases), isolated obstruction (1 case), and isolated regurgitation (1 case). Of the 4 patients with varying severity of ROVT obstruction, the average preprocedural peak jet velocity of RVOT was 3.5 m/s, and the average peak pressure gradient was 50.0 mmHg. Except for one patient, who had previously been implanted with a covered Cheatham-Platinum (CP) stent due to severe stenosis of the main pulmonary artery, other patients underwent pre-stenting with a covered CP stent before TPVR. Clinical implant success was achieved in all of the 5 patients, and there was no serious periprocedural complications. The average trans-pulmonary peak jet velocity and peak pressure gradient derived from postprocedural echocardiography was 2.3 m/s and 21.2 mmHg, respectively. All patients experienced significant symptom relief after the procedure. All patients completed 3-month follow-up, and 4 completed 6-month follow-up. There was no case of infectious endocarditis during follow-up. All patients were graded as NYHA functional class one at the latest follow-up. Conclusions: TPVR using the domestically-produced balloon-expandable Prizvalve system is safe and feasible for the treatment of patients with post-surgical RVOT dysfunction and suitable landing-zone anatomy. The safety, effectiveness, and long-term valve durability of the Prizvalve system deserve further research.

Hot topics in congenital heart disease: tetralogy of Fallot, Ross operation, immunodeficiency, cardiac arrest, and end-stage heart failure.

Hot topics in congenital heart disease: tetralogy of Fallot, Ross operation, immunodeficiency, cardiac arrest, and end-stage heart failure.

The Ross procedure using bicuspid and quadricuspid pulmonary valves.

The Ross procedure using bicuspid and quadricuspid pulmonary valves.

Ross procedure versus pulmonary homograft versus mechanical valve versus bioprosthetic valve versus Ozaki procedure for surgical aortic valve replacement: a frequentist network meta-analysis

BackgroundThere has been a resurgence in interest regarding the Ross procedure due to recent publications detailing positive long-term outcomes. Conversely, surgical aortic valve replacement (SAVR) with a pulmonary homograft (PH), mechanical (MV), bioprosthetic (BV), or the Ozaki procedure each has its own technical advantages and disadvantages. Therefore, we performed a network meta-analysis (NMA) comparing other alternatives to Ross procedure.MethodsMedical databases were comprehensively searched for studies comparing the Ross procedure with AVR using a PH, MV, BV, or the Ozaki procedure. Outcomes were pooled as risk ratios (RR) with their 95% confidence intervals (95% CI).ResultsA total of 7816 patients were pooled for our NMA from 24 studies. Compared to Ross procedure, both BV and MV were associated with significantly higher rates of 30-day mortality of RR (2.37, 95% CI 1.20–4.67) and (1.88 95% CI 1.04–3.40), respectively, with no significant difference regarding PH or Ozaki. However, only MV was associated with a higher risk of 30-day stroke (RR 8.42, 95% CI 1.57–45.23) with no significant difference in the other alternatives, as well as 30-day MI which showed no significant differences between any of the aortic conduits compared to the Ross procedure. Regarding 30-day major bleeding, MV was associated with a higher when compared to the Ross procedure RR (4.58, 95% CI 1.94–10.85), PH was associated with a lower risk of major bleeding with RR (0.35, 95% CI 0.17–0.71), and BV showed no significant difference. With a mean follow-up duration of 8.5 years compared to the Ross procedure, BV, PH, and MV were associated with a higher risk of long-term mortality with RR (1.89, 95% CI 1.38–2.58), (1.38, 95% CI 1.0–1.87), and (1.94, 95% CI 1.52–2.47), respectively, with the Ozaki procedure showed no significant difference. Regarding long-term stroke—with a mean of 6.3-year follow-up duration—there were no significant differences between any of the aortic conduits compared to the Ross procedure. Nevertheless, long-term need for reintervention—with a mean follow-up duration of 17.5 years—was significant of higher risk with both BV and PH with RR (3.28, 95% CI 1.21–8.84) and (2.42, 95% CI 1.05–5.58), respectively, compared to Ross procedure with MV and Ozaki having no significant difference.ConclusionsThe Ross procedure is a viable treatment option for patients undergoing SAVR, showing promising outcomes at short- and long-term follow-ups.

Outcomes of the Ross procedure in patients older versus younger than 50 years old.

The Ross procedure is traditionally considered for young adult patients with aortic valve disease. This study compares long-term outcomes of patients undergoing the Ross procedure who are ≥50 and <50-years old. Data were collected from 225 patients undergoing Ross procedure at a single centre from 1994 to 2019. Patients were categorized into younger (<50-years old; n = 156) and older (≥50-years old; n = 69) cohorts. Baseline demographics clinical outcomes were compared. The mean age was 36 ± 8.1 and 55 ± 4.2 years in the younger and older cohort, respectively. Both groups were predominantly male (58.5% vs 69.6%; P = 0.59). The younger group had a higher rate of aortic insufficiency (51% vs 26.1%; P < 0.01), and bicuspid aortic valve (81.4% vs 58.0%; P < 0.01). Aortic stenosis was more prevalent in the older cohort (25.6% vs 58.0%; P < 0.01). Operative mortality was acceptable in both groups (1.3% vs 4.3%; P = 0.15). Survival up to 10 years was not statistically different between 2 groups (96.2% vs 91.3% P = 0.16), whereas survival up to 15 years for younger patients was significantly higher (94.9% vs 85.5%; P = 0.03). After non-cardiac related deaths were excluded, survival up to 15 years (98.7% vs 91.3%; P = 0.02) was significantly lower than younger patients. In both groups, survival after the Ross procedure was similar to the age- and sex-matched US population. Survival up to 10 years after Ross procedure were similar, but up to 15 years was significantly higher in younger patients. The Ross procedure restored patients from both groups to expected survival. Our results suggest that at experienced centres, the Ross procedure is a safe and reasonable option for patients who are 50 years and older.

Valve-sparing operations after Ross procedure: a single-center experience.

The Ross procedure has demonstrated excellent long-term results, with restoration of life-expectancy in patients with severe aortic valve dysfunction. However, reintervention after Ross can occur, and herein we describe our center's experience with redo surgery after previous Ross procedures. We searched our prospective database for aortic valve-repair and recruited all adult (≥18 years) patients who have undergone valve-sparing root replacements (VSRRs) and/or aortic valve-repair after Ross procedure between July 2001 and July 2022. Univariable logistic regression analysis was performed to identify variables affecting early mortality. Survival, freedom-from-valve-reintervention and freedom-from-aortic regurgitation (AR) grade ≥3 were analyzed with the Kaplan-Meier method. A total of 63 patients were recruited for this study. Indication for reoperation after Ross was aortic aneurysm without AR in 17 (27%), aortic aneurysm with AR in 27 (43%), and isolated AR in 19 (30%) patients. Median follow-up time was 7.82 years. The majority of patients (76%) had undergone the free root technique during their index Ross operation. Cumulative survival, after redo surgery following Ross, was 98.4% [95% confidence interval (CI): 89.3-99.8%] at 1 year, 96.3% (95% CI: 88.2-98.3%) at 5 years, and 92.4% (95% CI: 87.1-98.0%) at 10 years. Freedom-from-reoperation on the aortic valve at 1 year was 98.4% (95% CI: 97.0-99.8%), at 5 years was 96.7% (95% CI: 87.6-99.0%), and 79.7% (95% CI: 71.1-88.3%) at 10 years. Long-term survival after redo surgery following the Ross operation is excellent. The data support our aggressive valve-sparing approach after Ross.

Pulmonary Homograft vs Handmade Polytetrafluoroethylene-Valved Conduits After the Ross Procedure

BackgroundThis study aimed to longitudinally compare expanded polytetrafluoroethylene (ePTFE)–valved conduits vs pulmonary homograft (PH) conduits after right ventricular outflow tract reconstruction in the Ross procedure. MethodsPatients undergoing a Ross procedure from June 2004 to December 2021 were identified. Echocardiographic data, catheter-based interventions, or conduit replacements, as well as time to first reintervention or replacement, were comparatively assessed between handmade ePTFE-valved conduits and PH conduits. ResultsA total of 90 patients were identified. The median age and weight were 13.8 years (interquartile range [IQR], 8.08-17.80 years) and 48.3 kg (IQR, 26.8-68.7 kg), respectively. There were 66% (n = 60) ePTFE-valved conduits and 33% (n = 30) PHs. The median size was 22 mm (IQR, 18-24 mm) for ePTFE-valved conduits and 25 mm (IQR, 23-26 mm) for PH conduits (P < .001). Conduit type had no differential effect in the gradient evolution or the odds of presenting with severe regurgitation in the last follow-up echocardiogram. Of the 26 first reinterventions, 81% were catheter-based interventions, without statistically significant differences between the groups (69% PH vs 83% ePTFE). The overall surgical conduit replacement rate was 15% (n = 14), and it was higher in the homograft group (30% vs 8%; P = .008). However, conduit type was not associated with an increased hazard for reintervention or reoperation after adjusting for covariates. ConclusionsRight ventricular outflow tract reconstruction using handmade ePTFE-valved conduits after a Ross procedure provides encouraging midterm results, without a differential effect in hemodynamic performance or valve function compared with PH conduits. These results are reassuring about the use of handmade valved conduits in pediatric and young adult patients. Longer follow-up of tricuspid conduits will complement valve competency assessment.

Pulmonary Autograft Dilatation and its Risk Factors After Classical Ross Procedure: a Retrospective Single Center Study

Introduction. Aortic valve replacement with pulmonary autograft (Ross procedure) demonstrated excellent immediate and long-term results. Dilation of the pulmonary autograft in the long-term period is the main reason for repeated surgery. Aim: to study the prevalence of pulmonary autograft dilatation and its risk factors. Materials and methods. From April 2009 to December 2022, 158 patients underwent classical Ross surgery. Inclusion criteria: patients aged 18 and older, patients who underwent classical surgery. Exclusion criteria: patients under 18, modifi ed methods of Ross procedure. Follow-up period: 104 (49–124) months. Results and discussion. The median age of patients was 33 (25–43) years. Hospital mortality accounted for 0.6 %. Perioperative myocardial injury was 3.8 %, conduction disorder requiring permanent pacemaker implantation accounted for 1.9 %, the incidence of strokes and acute kidney injury requiring hemodialysis was 0.6 %. Ten-year freedom from autograft reoperation was 88.4. Ten-year freedom from reoperation for aortic aneurysm accounted for 92 %. Predictors of autograft dilatation in the long-term period were: age (OR: 0.942; 95% CI: 0.901–0.984, p = 0.008) and the initial size of sinuses of Valsalva (OR: 1.18; 95% CI: 1.027–1.215, p = 0.01). Conclusion. Ten-year freedom from autograft reoperation due to aortic dilatation and freedom from aortic dilatation ≥ 45 mm was 92 % and 37.2 %, respectively. The main predictors of autograft dilatation in the postoperative period are the age and the initial diameter of the sinuses of Valsalva.

Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure

ObjectivePrimary aortic insufficiency (AI) is a risk factor for autograft reintervention in adults undergoing the Ross procedure. We sought to examine the influence of preoperative AI on autograft durability in children and adolescents. MethodsFrom 1993 to 2020, 125 consecutive patients between ages 1 and 18 underwent a Ross procedure. The autograft was implanted using a full-root technique in 123 (98.4%) and included in a polyethelene terephthalate graft in 2 (1.6%). Patients with aortic stenosis (aortic stenosis group) (n = 85) were retrospectively compared with those with AI or mixed disease (AI group) (n = 40). Median length of follow-up was 8.2 years (interquartile range, 3.3-15.4 years). The primary end point was the incidence of severe AI or autograft reintervention. Secondary end points included changes in autograft dimensions analyzed using mixed-effect models. ResultsThe incidence of severe AI or autograft reintervention was 39.0% ± 13.0% in the AI group and 8.8% ± 4.4% in the aortic stenosis group at 15 years (P = .02). Annulus z scores increased in both aortic stenosis and AI groups over time (P < .001). However, the annulus dilated at a faster rate in the AI group (absolute difference, 3.8 ± 2.0 vs 2.5 ± 1.7; P = .03). Sinus of Valsalva z scores increased in both groups as well (P < .001), but at similar rates over time (P = .11). ConclusionsChildren and adolescents with AI undergoing the Ross procedure have higher rates of autograft failure. Patients with preoperative AI have more pronounced dilatation at the annulus. Akin to adults, a surgical aortic annulus stabilization technique that modulates growth is needed in children.

LONG-TERM HEMODYNAMIC OUTCOMES OF DIFFERENT AORTIC VALVE INTERVENTIONS – A REVIEW OF COMPARATIVE STUDIES

Highlights Valve replacements using mechanical prostheses are not inferior, and sometimes even advantageous to bioprostheses in terms of transvalvular hemodynamics and left ventricle reverse remodeling;During the average follow-up period, a significantly lower average pressure gradient and a higher effective opening area were recorded in the group undergoing neocuspidization with autologous pericardium compared to other types of implants;Despite the obvious hemodynamic advantages of transcatheter aortic valve replacement, the midterm follow-up has revealed significant residual aortic regurgitation, which is highly undesirable. AbstractCurrently, there are not enough data on the comparative analysis of echocardiographic outcomes, especially in regards to the state of the left ventricle in the long term after different aortic valve interventions. In this review, we present up-to-date literature data (publications published over 20 years) concerning echocardiographic outcomes after different aortic valve replacements. For the search of publications, the authors used international databases such as Scopus, Web of Science, Pubmed and Cochrane. The search keywords were: “aortic valve surgery”, “long-term period”, “echocardiographic outcomes”, “quality of life”. The analysis includes only comparative randomized, prospective or retrospective studies. A comparison between mechanical and biological prostheses has demonstrated that mechanical valves, in addition to displaying higher durability, can be advantageous in certain situations to bioprostheses in relation to transvalvular hemodynamics and reverse left ventricle remodeling. Regarding the comparison of stentless and stented bioprostheses with respect to peak transvalvular gradients and the effective orifice area, an obvious advantage was observed in the stentless bioprosthesis group. The majority of randomized clinical trials have showed great hemodynamic advantages of the Ross procedure in comparison with other types of aortic valve replacement, and an increase in the number of participants (due to future trials) may demonstrate even greater statistical significance. We have found only one publication that presents data on the comparison of the mid-term hemodynamic outcomes of neocuspidization of the aortic valve using autologous pericardium with other types of interventions. With an average follow-up period of 426±270 days, a significantly lower average pressure gradient and a higher effective orifice area were recorded in the neocuspidization group. Despite hemodynamic benefits of transcatheter aortic valve replacement in the mid-term period after surgery, the results of postoperative monitoring show significant residual aortic regurgitation, which is highly undesirable.

Accuracy of pulmonary venous flow quantification by 2D phase contrast cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: None. Background Determination of pulmonary venous flow by cardiac magnetic resonance (CMR) is frequently required in patients with complex congenital heart disease (CHD) lesions. Although new advanced imaging techniques like 4D flow are increasingly available, standard 2D phase contrast (2DPC) sequences remain the most frequently used method for quantification of flow. However, little is known on the accuracy of 2DPC flow measurements in the pulmonary veins. Purpose This study therefore aims to investigate the accuracy of pulmonary venous flow quantification by 2DPC. Methods Patients with CHD underwent a CMR on a 1.5T scanner. 2DPC flow sequences (typical temporal resolution 35–50ms, inplane spatial resolution 1.3–1.8 mm2, VENC 80–100) were acquired in the ascending aorta (AA), main, right and left pulmonary arteries (MPA, RPA, LPA), as well as left (LPV) and right (RPV) pulmonary veins. Pulmonary venous flow was compared to pulmonary arterial flow in all patients and to aortic flow in patients without left to right (L-R) shunt using Bland-Altman plots and Pearson’s correlations. Results Twenty CHD patients (age 27±3, range 7; 53 years, 7 women, tetralogy of Fallot N=7, Ross operation N=1; Fontan N=4, transposition of great arteries N=2, atrial septal defect N=2, Turner syndrome 1, Ebstein N=1, valvulopathies N=2) were included. Table 1 shows absolute flow values of the different vessels. Bland-Altman analyses and correlations (Table 2) showed a good agreement of total pulmonary venous (PV) to flow in the ascending aorta (group without shunt) and the sum of flow of both branch pulmonary arteries. However, agreement of total PV with MPA flow as well as of LPV and RPV with the respective branch pulmonary artery flow was reduced. Conclusions Total PV flow determined by 2DPC shows a good agreement with flow in the ascending aorta and the sum of the branch pulmonary arteries. Flow turbulences due to the pathologies of the right ventricular outflow tract probably contribute to the reduced agreement of total PV and MPA flow. However, the reduced agreement of the flow in left/right pulmonary veins and their respective branch pulmonary arteries underlines the need for newer advanced flow quantification techniques to improve accuracy of pulmonary venous flow measurements.