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.

1. Tsaroev B., Chernov I., Enginoev S., Mustaev M. Survival and freedom from reoperation after the Ross procedure in a Russian adult population: A single-center experience. JTCVS Open. 2022; 10: 140–7. DOI: 10.1016/j.xjon.2022.04.026

2. Flynn C. D., Bono J. H. De, Muston B., Rattan N., Tian D. H., Larobina M., et al. Systematic review and meta-analysis of long-term outcomes in adults undergoing the Ross procedure. Ann Cardiothorac Surgery. 2021; 10 (4): 411–9. DOI: 10.21037/acs-2021-rp-30

3. David T. E., Ouzounian M., David C. M., Lafreniere-Roula M., Manlhiot C. Late results of the Ross procedure. J Thorac Cardiovasc Surg. 2019; 157: 201–8. DOI: 10.1016/j.jtcvs.2018.06.037

4. Buratto E., Shi W. Y., Wynne R., Poh C. L., Larobina M., O’Keefe M., et al. Improved survival after the Ross procedure compared with mechanical aortic valve replacement. J Am Coll Cardiol. 2018; 71: 1337–44. DOI: 10.1016/j.jacc.2018.01.048

5. Mazine A., Rocha R. V., El-Hamamsy I., Ouzounian M., Yanagawa B., Bhatt D. L., et al. Ross procedure vs mechanical aortic valve replacement in adults: a systematic review and meta-analysis. JAMA Cardiol. 2018; 3: 978–87. DOI: 10.1001/jamacardio.2018.2946

6. Gofus J., Fila P., Drabkova S., Zacek P., Ondrasek J., Nemec P., et al. Ross procedure provides survival benefi tover mechanical valve in adults: a propensity-matched nationwide analysis. Eur J Cardio-Thoracic Surg. 2022; 61: 1357–65. DOI:10.1093/ejcts/ezac013

7. Otto C. M., Nishimura R. A., Bonow R. O., Carabello B. A., Erwin J. P. 3^rd, Gentile F., et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American college of cardiology / American heart association joint committee on clinical practice guidelines. Circulation. 2021; 143: e35–71. DOI: 10.1161/CIR.0000000000000932

8. Chambers J. C., Somerville J., Stone S., Ross D. N. Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series. Circulation. 1997; 96: 2206–14. DOI: 10.1161/01.cir.96.7.2206

9. Elkins R. C., Lane M. M., McCue C. Pulmonary autograft reoperation: incidence and management. Ann Th orac Surg. 1996; 62: 450–5. PMID: 8694604.

10. Abeln K. B., Ehrlich T., Souko I., Brenner F., Schäfers H. J. Autograft reoperations after the Ross procedure. Eur J Cardiothorac Surg. 2023; 63 (5): ezad117. DOI: 10.1093/ejcts/ezad117

11. Romeo J. L. R., Papageorgiou G., da Costa F. F. D., Sievers H. H., Bogers A. J. J. C., El-Hamamsy I., et al. Long-term clinical and echocardiographic outcomes in young and middle-aged adults undergoing the Ross Procedure. JAMA Cardiol. 2021; 6 (5): 539–48. DOI: 10.1001/jamacardio.2020.7434

12. Bichell D. P. Autograft root dilation after the Ross procedure is not benign. World J Pediatr Congenit Heart Surg. 2021; 12 (4): 516–7. DOI: 10.1177/21501351211015927

13. Kalogerakos P. D., Zafar M. A., Li Y., Mukherjee S. K., Ziganshin B. A., Rizzo J. A., et al. Root dilatation is more malignant than ascending aortic dilation. J Am Heart Assoc. 2021; 10: e020645. DOI: 10.1161/JAHA.120.020645

14. Malaisrie S. C., Szeto W. Y., Halas M., Girardi L. N., Coselli J. S., Sundt T. M., et al. The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg. 2021; 162: 735–58.e2. DOI: 10.1016/j.jtcvs.2021.04.053

15. Siudalska H., Kuśmierczyk M., Różański J., Petryka-Mazurkiewicz J., Kumor M., Michałowska A. M., et al. Aortic dissection after the Ross procedure. Kardiol Pol. 2021; 79 (6): 702–3. DOI: 10.33963/kp.15957

16. Richey S., Fiore A. C., Huddleston C. B. Type A aortic dissection after the Ross procedure. Ann Thorac Surg. 2018; 106: e105–6. DOI: 10.1016/j.athoracsur.2018.02.042

17. Hahn R. T., Roman M. J., Mogtader A. H., Devereux R. B. Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cardiol. 1992; 19: 283–8. DOI: 10.1016/0735-1097(92)90479-7

18. Nistri S., Sorbo M. D., Marin M., Palisi M., Scognamiglio R., Thiene G. Aortic root dilatation in young men with normally functioning bicuspid aortic valves. Heart. 1999; 82: 19–22. DOI: 10.1136/hrt.82.1.19

19. Ryan W. H., Squiers J. J., Harrington K. B., Goodenow T., Rawitscher C., Schaffer J. M., et al. Long-term outcomes of the Ross procedure in adults. Ann Cardiothorac Surg. 2021; 10: 499–508. DOI: 10.21037/acs-2021-rp-fs-28

20. Fujita B., Aboud A., Sievers H. H., Ensminger S. State-of-the-art: Insights from the Ross Registry. JTCVS Tech. 2021; 10: 396–400. DOI: 10.1016/j.xjtc.2021.05.027

21. Nappi F., Iervolino A., Avtaar Singh S. S. The effectiveness and safety of pulmonary autograft as living tissue in Ross procedure: a systematic review. Transl Pediatr. 2022; 11 (2): 280–97. DOI: 10.21037/tp-21-351

22. Hanke T., Charitos E. I., Stierle U., Robinson D. R., Hemmer W., Moritz A., et al. The Ross operation — a feasible and safe option in the setting of a bicuspid aortic valve? Eur J Cardio-Thoracic Surg. 2010; 38: 333–9. DOI: 10.1016/j.ejcts.2010.01.064

23. Sharifulin R., Bogachev-Prokophiev A., Zheleznev S., Demin I., Pivkin A., Afanasyev A., et al. Factors impacting long-term pulmonary autograft durability after the Ross procedure. J Thorac Cardiovasc Surg. 2019; 157: 134–41.e3. DOI: 10.1016/j.jtcvs.2018.05.046

24. Girdauskas E., Disha K., Raisin H. H., Secknus M.-A., Borger M. A., Kuntze T. Risk of late aortic events aft er an isolated aortic valve replacement for bicuspid aortic valve stenosis with concomitant ascending aortic dilation. Eur J Cardio-Thoracic Surg. 2012; 42: 832–8. DOI: 10.1093/ejcts/ezs137

25. Girdauskas E., Disha K., Rouman M., Espinoza A., Borger M. A., Kuntze T. Aortic events after isolated aortic valve replacement for bicuspid aortic valve root phenotype: echocardiographic follow-up study. Eur J Cardio-Thoracic Surg. 2015; 48: e71–6. DOI: 10.1093/ejcts/ezv259

26. Chernov I. I., Enginoev S. T., Kondrat’ev D. A., Zenkov A. A., Abdurakhmanov A. A., Tarasov D. G. The David procedure aft er the Ross operation: case series. Russian Journal of Cardiology. 2021; 26 (S4): 4767 (In Russ.). DOI: 10.15829/1560-4071-2021-4767

27. Skillington P. D., Mokhles M. M., Takkenberg J. J. M., Larobina M., O’Keefe M., Wynne R., et al. The Ross procedure using autologous support of the pulmonary autograft : techniques and late results. J Thorac Cardiovasc Surg. 2015; 149: S46–52. DOI: 10.1016/j.jtcvs.2014.08.068

28. Slater M., Shen I., Welke K., Komanapalli C., Ungerleider R. Modification to the Ross procedure to prevent autograft dilatation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005: 181–4. DOI: 10.1053/j.pcsu.2005.01.022

29. Starnes V. A., Elsayed R. S., Cohen R. G., Olds A. P., Bojko M. M., Mack W. J., et al. Long-term outcomes with the pulmonary autograft inclusion technique in adults with bicuspid aortic valves undergoing the Ross procedure. J Thorac Cardiovasc Surg. 2023; 165 (1): 43–52.e2. DOI: 10.1016/j.jtcvs.2021.01.101

30. Nappi F., Spadaccio C., Castaldo C., Di Meglio F., Nurzynska D., Montagnani S., et al. Reinforcement of the pulmonary artery autograft with a polyglactin and polydioxanone mesh in the Ross operation: experimental study in growing lamb. J Heart Valve Dis. 2014 Mar; 23 (2): 145–8. PMID: 25076542.