Modified Ross procedure with pulmonary autograft reinforcement within a Valsalva Dacron graft: long-term results†

Abstract

Objectives: The Ross procedure allows the replacement of a diseased aortic valve with a living valvular substitute and provides a normal life span. However, progressive autograft dilatation and subsequent neoaortic valve regurgitation leading to reoperations remain major drawbacks. Our objective was to assess the long-term outcomes of our modified Ross technique with pulmonary autograft reinforcement in a Valsalva Dacron graft.

Methods: Data from all patients who underwent a modified Ross procedure in our institution between 2003 and 2020 were reviewed retrospectively.

Results: One hundred eighty-nine patients were included in this study. Median age at surgery was 31 years [interquartile range (IQR) 22.5-38.7]. Patients were predominantly male (74.1%) and with bicuspid aortic valve (90.5%). Indication for surgery was pure aortic regurgitation in 40.2%, pure aortic stenosis in 30.7%, mixed lesion in 26.5% and prosthetic valve failure in 2.7%. Median cardiopulmonary bypass and aortic cross-clamping times were 135 (IQR 120-171.5) and 114 (IQR 101.5-1423.5) min, respectively Three perioperative deaths occurred (1.6%). Median follow-up was 8.6 years (IQR 5.3-11.5); three late deaths occurred. Overall survival rate was 96.6% at both 5 and 10 years. Ten patients underwent 11 late autograft reinterventions. Freedom from autograft reoperation was 95.8% and 95.0% at 5 and 10 years, respectively. The main indication for autograft reoperation was neoaortic regurgitation due to cusp prolapse. With death as a competing outcome, we observed a trend towards an increased risk for autograft reintervention in patients with pure preoperative aortic regurgitation (sub-hazard ratio 4.47, P = 0.057; 95% confidence interval 0.95-20.9).

Conclusions: The modified Ross procedure with inclusion of the pulmonary autograft using a Valsalva Dacron graft showed excellent results at 10 years.

Keywords: Aortic root; Pulmonary autograft; Reinforcement; Ross procedure.