Annuloplasty and aortoplasty as modifications of the Ross procedure for the correction of geometric mismatch

Background and aim of the study: Pulmonary autograft replacement of the aor tic valve (the Ross procedure) is reliable and durable; however, geometric mismatch of the autograft and systemic outflow tract may lead to poor resul ts. Manipulation of the aortic annulus and sinotubular diameters to match t he autograft can prevent geometric mismatch, and improve results. Methods: Annuloplasty and/or aortoplasty were combined with the Boss proced ure in 26 of 44 patients (median age 42.5 years; range: 3 days to 62 years) undergoing surgery between April 1994 and July 1998. Plication of the aort ic annulus at either two or three of the commissures was done in five cases , aortic annulus fixation with an external pericardial pledget incorporated in the proximal suture line in 12 cases, and tailoring aortoplasty in nine patients. Results: There was one operative death. Two patients required reoperation; one for progressive autograft dysfunction and one for homograft dysfunction . Annular fixation was performed on the patient requiring reoperation for a utograft dysfunction. Doppler echocardiography during the follow up (median 9 months; range: 1-50 months) revealed 10 patients with trace 1+ and one p atient with 2+ aortic insufficiency. Trace 1+ and 2+ aortic stenosis were p resent in one patient each. None of the patients undergoing commissural pli cation had significant regurgitation or stenosis. Both patients with stenos is underwent annular fixation. Aortoplasty was associated with 1+ insuffici ency in two patients. Conclusion: Prevention of geometric mismatch between the autograft and syst emic outflow tract at the annulus and sinotubular junction by plication tec hniques allows better performance of the autograft, and extends the Ross pr ocedure to patients who otherwise may be unable to undergo such surgery. Fi xation may provide similar benefit, but appears to be more susceptible to i nsufficiency and stenosis.