The pulmonary autograft (Ross operation) as aortic valve replacement - Evolution and expansion of indications, techniques and results in 100 patients

The pulmonary autograft as aortic valve replacement has normal haemodynamic performance, can grow, and the patient does not require anticoagulation. T he technical demands of the operation and the two valves at risk have delay ed acceptance. A review of a single surgeon's experience in 100 consecutive patients (20 female, 80 male) operated on in Europe between February 1995 and February 1998 is presented. Patient ages ranged from 8 to 60 years (med ian 40.5 years). Aortic stenosis was the primary aortic valve pathology in 34 patients, incompetence in 25 and combined disease in 41. The operation w as a redo procedure in 14 patients, and combined cardiac procedures were un dertaken in 16. Follow-up has been complete to date. There have been no ear ly or late deaths. No thrombo-embolic events or endocarditis have occurred. Two patients have required reoperation due to valve dysfunction, one adult patient required late reoperation due to progressive annular dilation with incompetence of the pulmonary autograft, and a child required revision of the pulmonary homo-graft due to progressive stenoses of the homograft. Echocardiographic evaluation reveals trivial or no aortic regurgitation in 89 patients and the remaining II have clinically insignificant insufficienc y, graded as minimal. None of the pulmonary homografts in the right ventric ular outflow tract have significant insufficiency. The median peak systolic gradient across the pulmonary autograft (aortic valve) is 7.5 mmHg (standa rd deviation (SD) 3.4 mmHg, range 3 - 22), and for the pulmonary homograft on the right of the heart a median peak gradient of 8.8 mmHg (SD 4.7) range 3 - 30 mmHg was documented. A progressive increase in pulmonary homograft valve gradients has been seen in two children, one of whom has required reo peration. Excellent results are obtainable in the Ross operation, as shown by 100 con secutively operated patients without mortality or thrombo-embolic or haemor rhagic events. Owing to the unique advantages offered by a living and funct ionally normal aortic valve substitute without the need for systemic antico agulation the procedure deserves greater application, particularly in the e conomically disadvantaged societies of the developing world without sophist icated medical infrastructures.