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. 2023 Dec 12:10:1306445.
doi: 10.3389/fcvm.2023.1306445. eCollection 2023.

Redo aortic root surgery post-Ross procedure

Alexander Bogachev-Prokophiev  1 , Ravil Sharifulin  1 , Igor Demin  1 , Anastasiia Karadzha  1 , Sergey Zheleznev  1 , Alexander Karaskov  1 , Alexander Afanasyev  1 , Alexey Pivkin  1 , Mikhail Ovcharov  1 , Anton Zalesov  1 , Ivan Murashov  2 , Bashir Tsaroev  1 , Alexander Chernyavsky  1
Affiliations

Redo aortic root surgery post-Ross procedure

Alexander Bogachev-Prokophiev et al. Front Cardiovasc Med. .

Abstract

Background: Despite numerous advantages of the Ross procedure, it presents a risk of late autograft and right ventricular outflow tract conduit failure. This study aimed to analyze the outcomes of autograft dysfunction reoperations using autograft-sparing and root replacement techniques.

Methods: Between 2015 and 2023, 49 patients underwent redo root surgery in our institution. Autograft valve-sparing procedures (VSP) were performed in 20 cases and the Bentall procedure (BP) in 29 patients. The short and long-term clinical outcomes along with echocardiographic results of VSP and BP were investigated.

Results: Overall early mortality rate was 2.0% with no significant difference between the groups. Severe autograft valve insufficiency at the time of redo (OR 4.07, P = 0.03) and patient age (OR 1.07, P = 0.04) were associated with a valve replacement procedure instead of VSP. The median follow-up duration was 34 months. No late deaths occurred in either group. Freedom from VSP failure and aortic prosthesis dysfunction were 93.8% and 94.1% in the VSP and BP groups, respectively. No reoperations were necessary in either group.

Conclusion: Redo aortic root surgery can be safely performed in patients with autograft failure. Both root replacement and autograft valve-sparing procedures demonstrated acceptable results at mid-term follow-up. Early redo surgery pre-empting severe aortic insufficiency increases the likelihood of preservation of the dilated autograft valve.

Keywords: Bentall procedure; Ross procedure; pulmonary autograft; redo surgery; valve-sparing procedure.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Reimplantation (David) procedure for autograft aneurysm and moderate aortic insufficiency 11 years post-Ross procedure. (A) Computed tomography showing neo-aortic root and ascending aorta dilatation up to 56 mm. (B) Autograft valve after dissection and resection of the Valsalva sinuses, subvalvular U sutures are placed. (C) Aspect of autograft valve after re-implantation inside a tubular Dacron graft and central free margin plication of the leaflets. (D) Final view of operation, in the right ventricular outflow tract a new homograft was implanted.
Figure 2
Figure 2
Remodeling (Yacoub) procedure for autograft aneurysm and mild aortic insufficiency in 15 years post-Ross procedure. (A) Computed tomography 3D reconstruction showing neo-aortic root and ascending aorta dilatation up to 50 mm, the Melody valve in the pulmonary artery position (arrow). (B) Intraoperative view of the pulmonary autograft valve, no degenerative leaflets changes, no annulus dilatation. (C) Graft preparation, three tongues are formed. (D) The graft is sutured to the aortic root.
Figure 3
Figure 3
Neo-aortic root replacement (Bentall procedure) for autograft aneurysm and sever aortic insufficiency in 12 years post-Ross procedure. (A) Computed tomography showing neo-aortic root and ascending aorta dilatation up to 50 mm. (B) Intraoperative view of the autograft valve: fenestrations of noncoronary cusp. (C) U-shaped sutures are placed circumferentially. (D) Neo-aortic root replaced by valved graft.
Figure 4
Figure 4
Flow chart of patient enrolment.
Figure 5
Figure 5
Distribution of procedures over the years. BP, Bentall procedure; VSP, Valve-sparing procedures; AVR, isolated autograft valve replacement or repair.
Figure 6
Figure 6
Survival rates. BP, Bentall procedure; VSP, valve-sparing procedure.
Figure 7
Figure 7
Histological examination of autograft wall and leaflets, hematoxylin, and eosin stain. (A) Autograft wall. Intima thickening, disorganization of elastic fibers in the media (arrowheads), neovascularization on the border of media and adventitia (vasa vasorum, asterisk). A: adventitia; I: intima; M: media. (B) Pulmonary autograft leaflet. Thickening of the ventricularis (V), degenerative change of the spongiosa (S), and disorganization of collagen fibers (arrowheads). F: fibrosa.
Figure 8
Figure 8
Bentall procedure and hemi-Cabrol graft-left main anastomosis. (A) The left main coronary artery ostium (arrow) is close to the autograft annulus. (B,C) Нemi-Cabrol graft-left main anastomosis. (D) Computed tomography angiography after Bentall procedure and hemi-Cabrol graft-left main anastomosis (arrow).
Figure 9
Figure 9
Histological examination of autograft wall wrapped with Dacron graft. (A,B) Dacron graft with surrounding cellular reaction, hematoxylin, and eosin: many foreign body giant cells (black arrowheads), lymphocytes, macrophages. Dense fibrosis outside of the fabric (blue arrow). The asterisk (*) marks a neovessel. (C) Degenerative changes in the tunica media, Van Gieson's stain: Thinning of media, medionecrosis (asterisk), smooth muscle atrophy and apoptosis, breaking of elastic fibers.
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References

    1. Gofus J, Fila P, Drabkova S, Zacek P, Ondrasek J, Nemec P, et al. Ross procedure provides survival benefit over mechanical valve in adults: a propensity-matched nationwide analysis. Eur J Cardiothorac Surg. (2022) 61(6):1357–65. 10.1093/ejcts/ezac013 - DOI - PubMed
    1. Miskovic A, Monsefi N, Karimian-Tabrizi A, Zierer A, Moritz A. A 17-year, single-centre experience with the Ross procedure: fulfilling the promise of a durable option without anticoagulation? Eur J Cardiothorac Surg. (2016) 49:514–9. 10.1093/ejcts/ezv074 - DOI - PubMed
    1. Ratschiller T, Samez-Dolzer E, Schimetta W, Paulus P, Müller H, Zierer A, et al. Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure. J Thorac Cardiovasc Surg. (2018) 155(6):2390–7. 10.1016/j.jtcvs.2018.01.095 - DOI - PubMed
    1. Etnel JRG, Grashuis P, Huygens SA, Pekbay B, Papageorgiou G, Helbing WA, et al. The Ross procedure: a systematic review, meta-analysis, and microsimulation. Circ Cardiovasc Qual Outcomes. (2018) 11(12):e004748. 10.1161/CIRCOUTCOMES.118.004748 - DOI - PubMed
    1. Akins CW, Miller DC, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. J Thorac Cardiovasc Surg. (2008) 135:732–8. 10.1016/j.jtcvs.2007.12.002 - DOI - PubMed

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