Early results of the Ross procedure in simple and complex left heart disease

Background-The Ross procedure has been used increasingly to treat aortic va lve disease in children and young adults. Benefits include the lack of anti coagulation after surgery and the potential growth and durability of the au tograft. The purpose of this study was to review our institutional experien ce with the Ross procedure and to compare early outcome in simple aortic va lve disease and complex left heart disease. Methods and Results-Between January 1995 and October 1998, 66 patients (med ian age, 10.8 years) range, 6 days to 34.8 years underwent the Ross procedu re. The primary indication for surgery was isolated valvular disease in 41 patients: aortic stenosis (AS: n=3), aortic insufficiency (AI; n=11), and A S/AI (n=27), The remaining 25 patients had multiple levels of left ventricu lar outflow tract obstruction, 12 Of whom had at least moderate AI. Additio nal left heart disease in the complex group included subaortic stenosis (n= 20), arch obstruction (n=7), mitral valve disease (n=5), apical aortic cond uit stenosis or insufficiency (n=3), and supravalvar AS (n=2). There were 1 23 prior interventions performed in 51 patients, including aortic valvotomy /valvuloplasty (n=56), coarctation repair (n=21), subaortic stenosis resect ion/Konno procedure (n=10), ventricular septal defect closure (n=8), apical aortic conduit placement (n=3), aortic valve replacement (n=3), and other (n=22). An isolated Ross procedure was performed in 41 patients, 10 of whom required concurrent aortic annulus enlargement procedure to accommodate th e larger pulmonary autograft. In the remaining 25 patients, 49 concurrent p rocedures were performed, including the Konno procedure (n=17), aortic annu lus enlargement (n=2), subaortic membrane resection (n=9), arch augmentatio n (n=5), mitral valvuloplasty (n=5), ventricular septal defect closure (n=3 ), apicoaortic conduit division (n=3), and other (n=4). One patient (1.5%) died 3 days after a Ross-Konno procedure, which included arch reconstructio n, from presumed arrhythmia. There were no other early deaths. One patient required ECMO (extracorporeal membrane oxygenation) for 3 days after a vent ricular tachycardia (VT)-related cardiac arrest. Transient complete heart b lock was seen in 4 patients; the duration was <5 day;. No patient had left ventricular outflow tract obstruction on discharge echocardiography, Neo-AI was graded as none (n=5), trivial-mild (n=57), or moderate (n=3). All 3 pa tients with moderate neo-AI at discharge had abnormal pulmonary valves befo re surgery. Perioperative VT was noted in 18 patients (27.2%), 2 of whom we re discharged on antiarrhythmic medication. Conclusions-The Ross procedure can be performed in isolation or in combinat ion with other complex procedures with low mortality (1.5%) and acceptable short-term results, even in patients with complex left heart disease and mu ltiple prior interventions. Postoperative VT is common. Anatomic abnormalit ies of the pulmonary valve preclude its use as an autograft.