Search

Despite offering several potential benefits over standard prosthetic aortic valve replacement, the use of the pulmonary autograft has been limited to date due to concerns over the risk of pulmonary autograft expansion and the need for reintervention. Several techniques using materials with biomimetic potential have been developed to reduce this complication. The incidence, risk factors, and pathophysiology of pulmonary autograft dilatation are discussed in this article. This seminar will provide an overview of the techniques of external pulmonary autograft support and their advantages and limitations. It also considers future directions for further investigation and future clinical applications of external pulmonary autograft support. Dilatation of the autograft is more likely to occur in patients with aortic regurgitation and a dilated aortic annulus. External scaffolding may prevent autograft stretching and expansion in these specific cases. However, from a biomimetic point of view, any permanent scaffold potentially restricts the movement of the autograft root. This reduces some of the benefits associated with the use of autologous tissue, which is the priority of the Ross procedure. To address this issue, several bioresorbable matrices could be used to support the root during its initial adaptive phase. Control of blood pressure with aggressive therapy is the first line to avoid this problem in the first year after pulmonary autograft implantation, together with support of the annular and sinotubular junction in some selected cases. This is the best way to maintain stable autograft root dimensions while preserving root dynamics. However, to determine the efficacy of this combined external support and best medical management, it is important to perform regular imaging and clinical follow-up. [ABSTRACT FROM AUTHOR]

Background/Objectives: In an era of growing evidence for transaortic valve implantation (TAVI), our research topic was the evaluation of how surgical aortic valve replacements (SAVRs) are performing in terms of short- and long-term outcomes in different risk categories. Methods: This was a single centre, prospective, and observational cohort study of consecutive patients with aortic valve stenosis, undergoing isolated aortic valve replacement using a biological or mechanical prosthesis, Freestyle™ (Medtronic, Minneapolis, MN, USA) graft, homograft, or Ross procedure. The participant data were collected by review of an internal database. The primary endpoints were all-cause operative mortality (in hospital and at 30 days) and late mortality at the follow-up date. The secondary composite endpoint was the incidence of postoperative complications. Results: 1501 patients underwent SAVR; the mean age was 67 years (SD: 12.6). The in-hospital mortality was 1% (n = 16). At a median follow-up of 60 months, the survival rate was 98.7%. The main predictors for mortality were operative urgency and cardiogenic shock. The overall incidence of PPM was 2.3% (n = 34). Patients who underwent Ross procedure were younger (mean age: 20 years (SD: 1.7)), had a lower incidence of postoperative complications, and were all alive at follow-up. Conclusions: SAVR shows an excellent survival rate and a low rate of postoperative complications despite an increasing surgical risk. Recent advancements in technology, like sutureless/rapid deployment prostheses and minimally invasive techniques, are shown to have favourable effects on outcomes. [ABSTRACT FROM AUTHOR]

Despite offering several potential benefits over standard prosthetic aortic valve replacement, the use of the pulmonary autograft has been limited to date due to concerns over the risk of pulmonary autograft expansion and the need for reintervention. Several techniques using materials with biomimetic potential have been developed to reduce this complication. The incidence, risk factors, and pathophysiology of pulmonary autograft dilatation are discussed in this article. This seminar will provide an overview of the techniques of external pulmonary autograft support and their advantages and limitations. It also considers future directions for further investigation and future clinical applications of external pulmonary autograft support. Dilatation of the autograft is more likely to occur in patients with aortic regurgitation and a dilated aortic annulus. External scaffolding may prevent autograft stretching and expansion in these specific cases. However, from a biomimetic point of view, any permanent scaffold potentially restricts the movement of the autograft root. This reduces some of the benefits associated with the use of autologous tissue, which is the priority of the Ross procedure. To address this issue, several bioresorbable matrices could be used to support the root during its initial adaptive phase. Control of blood pressure with aggressive therapy is the first line to avoid this problem in the first year after pulmonary autograft implantation, together with support of the annular and sinotubular junction in some selected cases. This is the best way to maintain stable autograft root dimensions while preserving root dynamics. However, to determine the efficacy of this combined external support and best medical management, it is important to perform regular imaging and clinical follow-up.

Aim. To analyze the immediate outcomes of reinterventions after Ross procedure.Material and methods. From April 2009 to December 2022, 224 Ross operations in adults were performed at the Federal Center for Cardiovascular Surgery. The retrospective study included 17 patients who required repeated interventions (14 men/3 women). The mean age of the patients was 38±11 years, with a minimum age of 21 and a maximum of 54 years. A history of infective endocarditis was revealed in 4 (23,5%) patients, hypertension — in 3 (17,6%) patients. Of the 17 included patients, 15 patients underwent the classic Ross operation ("full root replacement"), while 2 — a modified technique (1 — wrapping with aorta, 1 — wrapping with a Dacron graft). Annulus enhancement was previously performed in 3 patients.Results. Interventions on the pulmonary autograft and homograft were performed in 16 and 4 cases, respectively. The main indication for pulmonary autograft intervention was aortic regurgitation in 15 cases, and neoaortic aneurysm in 14 cases. In 3 patients, there was pulmonary homograft stenosis, while in 1 case — thrombosis. Two patients required interventions on other valves: 1 — mitral valve stenosis, 1 — severe tricuspid regurgitation. Mean reoperation, cardiopulmonary bypass and myocardial ischemia time were 289±62, 126±35 and 98±22 min, respectively. Combined interventions were performed in 6 cases. David valve-sparing procedure was performed in 9 patients, Bentall-de Bono technique — in 3, aortic valve repair — in 2, mechanical aortic valve replacement — in 2, supracoronary ascending aorta replacement — in 2, pulmonary homograft replacement — in 2, pulmonary homograft thrombectomy — in 1, pulmonary homograft repair — in 1 patient, mitral valve replacement — in 1 patient, tricuspid valve repair — in 1 patient. One patient required resternotomy for bleeding. There were no postoperative complications (perioperative myocardial infarction, acute kidney injury, stroke, sternal infection, cardiac tamponade) and deaths. The median length of stay in intensive care unit was 21 [16-23] hours.Conclusion. Reoperations after the Ross procedure may be required for different pathologies, but all can be performed surgically with a high safety in experienced operator.

Congenital heart disease (CHD) remains a predisposing cardiac condition for infective endocarditis (IE). Case report: We present the case of 8-year-old boy with no known pre-existing cardiac disease diagnosed with infective endocarditis (IE) with Gemella sanguinis. After admission, he underwent transthoracic echocardiography (TTE), which revealed the presence of Shone syndrome with a bicuspid valve, mitral parachute valve and severe aortic coarctation. He developed a paravalvular aortic abscess with severe aortic regurgitation and left ventricle (LV) systolic dysfunction for which he required a complex surgical intervention after six weeks of antibiotic treatment, consisting of Ross operation and coarctectomy, with a complicated postoperative course, cardiac arrest and ECMO support for five days. The evolution was slow and favorable, with no significant residual valvular lesions. However, persistent LV systolic dysfunction and increased muscle enzymes required further investigation to establish a genetic diagnosis of Duchenne disease. As Gemella is not considered a frequent pathogen of IE, no current guidelines refer specifically to it. Additionally, the predisposing cardiac condition of our patient is not currently classified as "high-risk" for IE; this is not considered an indication for IE prophylaxis in the current guidelines. Conclusion: This case illustrates the importance of accurate bacteriological diagnosis in infective endocarditis and poses concerns regarding the necessity of IE prophylaxis in "moderate risk" cardiac conditions such as congenital valvular heart disease, especially aortic valve malformations. [ABSTRACT FROM AUTHOR]

The Ross procedure is superior as a valve substitute in children and early adulthood because of its clear survival benefits. The free standing-root implantation is associated with failure of the autograft and inclusion techniques that support externally the autograft warrants its longevity. The current technique consists in the implantation of the autograft within the native aortic root thereby both supporting the autograft and avoiding any coronary distortion. [ABSTRACT FROM AUTHOR]

Autograft stabilization has proven beneficial in adults but the same technique could not always be adopted in growing children undergoing the Ross procedure. The major concern regarding the longevity of autograft after the Ross operation in a growing child is the lack of means to stabilize the aortic root. Herein we described a modified root inclusion technique that achieves aortic root stabilization using autologous tissue. [ABSTRACT FROM AUTHOR]

Background: Although pregnancy outcomes in women with normally functioning bioprosthetic valves (BPVs) are often good, structural valve dysfunction (SVD) may adversely affect pregnancy outcomes, but this has not been studied.Objectives: The aim of this study was to examine outcomes in pregnant women with BPVs and the association with SVD.Methods: Pregnancy outcomes in women with BPVs were prospectively collected. Adverse maternal cardiac events (CEs) included cardiac death or arrest, sustained arrhythmia, heart failure, thromboembolism, and stroke. Adverse fetal events were also studied. Determinants of adverse events were examined using logistic regression.Results: Overall, 125 pregnancies in women with BPVs were included, 27% with left-sided and 73% with right-sided BPV. SVD was present in 27% of the pregnancies (44% with left-sided BPVs vs 21% with right-sided BPVs; P = 0.009). CEs occurred in 13% of pregnancies and were more frequent in women with SVD compared with those with normally functioning BPVs (26% vs 8%; P = 0.005). CEs were more common in women with left-sided BPVs with SVD vs normally functioning BPVs (47% vs 5%; P = 0.01) but not in women with right-sided BPVs (11% in those with SVD vs 8% in those without SVD; P = 0.67). Left-sided SVD (P = 0.007), maternal age >35 years (P = 0.001), and a composite variable of "high-risk" features (P = 0.006) were predictors of CEs. Fetal events occurred in 28% of pregnancies.Conclusions: In this cohort of young women with BPVs, SVD was present in 27% at the first antenatal visit and negatively affected pregnancy outcomes. In particular, SVD of left-sided BPVs was associated with high rates of adverse outcomes. [ABSTRACT FROM AUTHOR]

Background Anomalous coronary origin from the left ventricular outflow tract (LVOT) is an exceedingly rare condition thought to be associated with the bicuspid aortic valve (BAV). While the malignant presentation of this entity has been described, its pathophysiology and diagnostic evaluation are poorly understood. Case summary A 33-year-old woman status post Ross procedure in childhood for congenital aortic stenosis due to BAV with presumed common origin of right and left coronary arteries based on single coronary ostium seen on aortic valve inspection, presented with symptomatic pulmonary regurgitation and stenosis. Invasive left coronary angiography revealed retrograde filling of the right coronary artery (RCA) with systolic washout of contrast indicating a patent RCA ostium. No RCA ostium was found on aortic root injection, but an injection into the LVOT revealed an RCA ostium below the aortic valve. Selective RCA angiography revealed pulsatile antegrade flow down the RCA occurring during systole. There was no anatomic RCA stenosis. We proceeded with valve-in-valve TcPVR. The patient had significant improvement of symptoms and RCA reimplantation was hence deferred. Discussion This case is the first of an anomalous coronary artery arising from the LVOT diagnosed in a patient after the Ross procedure. Our angiograms shed light on the unusual physiology of coronary filling during systole and ischaemia arising from inadequate perfusion gradient between the left ventricle and the coronary during systole, leading to collateralization despite the lack of anatomic stenosis. We urge consideration of this potentially malignant entity in any symptomatic patient, especially with concomitant BAV. [ABSTRACT FROM AUTHOR]

Congenital heart disease (CHD) remains a predisposing cardiac condition for infective endocarditis (IE). Case report: We present the case of 8-year-old boy with no known pre-existing cardiac disease diagnosed with infective endocarditis (IE) with Gemella sanguinis. After admission, he underwent transthoracic echocardiography (TTE), which revealed the presence of Shone syndrome with a bicuspid valve, mitral parachute valve and severe aortic coarctation. He developed a paravalvular aortic abscess with severe aortic regurgitation and left ventricle (LV) systolic dysfunction for which he required a complex surgical intervention after six weeks of antibiotic treatment, consisting of Ross operation and coarctectomy, with a complicated postoperative course, cardiac arrest and ECMO support for five days. The evolution was slow and favorable, with no significant residual valvular lesions. However, persistent LV systolic dysfunction and increased muscle enzymes required further investigation to establish a genetic diagnosis of Duchenne disease. As Gemella is not considered a frequent pathogen of IE, no current guidelines refer specifically to it. Additionally, the predisposing cardiac condition of our patient is not currently classified as “high-risk” for IE; this is not considered an indication for IE prophylaxis in the current guidelines. Conclusion: This case illustrates the importance of accurate bacteriological diagnosis in infective endocarditis and poses concerns regarding the necessity of IE prophylaxis in “moderate risk” cardiac conditions such as congenital valvular heart disease, especially aortic valve malformations.

One of the surgical methods for treating aortic valve pathology is the Ross operation, which was proposed by the British cardiac surgeon D. Ross in 1967. Numerous studies have shown excellent long-term outcomes of this operation. However, in some patients, pulmonary autograft dilatation may occur in the long term. To avoid this complication, technical modifications of this procedure have been proposed. A literature review on modified Ross operation as a prevention of pulmonary autograft dilatation is presented.

Pulmonary autograft in the aortic position provides high survival rate and quality of life for patients, low incidence of valve-related complications, and excellent hemodynamic characteristics both in the early and long-term period. However, in some patients in the long-term period, pulmonary autograft may dilate, which in turn is one of the reasons for reoperations. In patients who require surgery for annuloaortic ectasia with aortic valve (AV) regurgitation or aortic root aneurysm (or both) with normal AV leaflets, David procedure is considered.Aim. To analyze results of David procedure after a prior Ross operation.Material and methods. From April 2009 to December 2020, 212 Ross operations were performed on patients 18 years of age and older. The median age of the operated patients was 34 (27-45) years. In the long-term period, 10 (4,7%) patients required a second AV operation and 7 (3,3%) of them required another intervention on the ascending aorta due to aortic dilatation. Four out of 10 patients underwent David procedure. The follow-up period for patients after David procedure ranged from 2 to 84 months.Results. The age of patients ranged from 23 to 45 years. Three patients had hypertension. The follow-up period from Ross's operation to David's one was 26 to 140 months. All patients had enlarged aortic annulus from 27 to 30 mm. The duration of myocardial ischemia ranged from 87 to 142 minutes, while the duration of artificial circulation — from 119 to 165 minutes. The graft diameter was 30 mm in two patients and 32 mm in the remaining ones. The length of stay in intensive care unit ranged from 16 to 23 hours. In the early postoperative period, no one had following postoperative complications: acute renal failure requiring hemodialysis, perioperative myocardial injury, stroke, sternal infection, respiratory failure requiring mechanical ventilation for ≥24 hours, resternotomy for bleeding and tamponade. In addition, there were no in hospital deaths. All patients had no aortic regurgitation at the time of discharge. All patients are alive and there were no reoperations. In one patient, in the long-term period, there was a mild aortic regurgitation, while in three patients — there is no regurgitation.Conclusion. The presented case series show that David procedure can be performed safely and effectively in a significant number of patients requiring a second autograft surgery due to neosinus dilatation. In the medium term, the David procedure has shown good outcomes in these patients with 100% survival and no aortic regurgitation and reoperation.

Introduction and Objectives: The Ross procedure is the preferred surgical treatment for pediatric aortic valve diseases, and its long-term outcomes have been extensively documented. This article presents the results of the Ross and Ross-Konno procedures performed on pediatric patients in our center., Methods: Ross and Ross-Konno procedures were performed on 20 patients in our center between January 2015 and January 2019., Results: The patients' mean age was 10.6 years (range: 23 days to 18 years) and mean weight was 37.6 kg (range: 3-63 kg). Thirteen had aortic valve stenosis, four had aortic valve insufficiency, and three had a mixed disease. The Ross-Konno procedure was used for four patients. The mean cardiopulmonary bypass time was 184.68±60.1 min and the mean cross time was 149±67.8 min. One neonatal patient died in the early postoperative phase due to low cardiac output. The mean follow-up time was 60.15±24.45 months. One patient later underwent reoperation due to conduit stenosis. One patient is being monitored for moderately serious conduit stenosis. At present, of those who underwent the procedure, one has moderate aortic regurgitation, two have mild or moderate aortic regurgitation, and others have minimal aortic regurgitation. No patients required intervention for left ventricular outflow tract obstruction and mortality was not observed in the long term., Conclusion(s): The reintervention rates for autograft and conduit-related cases were low in early and medium-term follow-up, and no significant autograft insufficiency was observed. Ross or Ross-Konno surgery is preferred for aortic diseases in pediatric patients due to its low mortality and satisfactory long-term results., (Copyright © 2024 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

[Display omitted] [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide We sought to evaluate the outcome after modified subcoronary Ross/Ross–Konno operation in children and young adults. METHODS Between January 2013 and January 2019, a total of 50 patients with median age of 6.3 years (range 0.02–36.5 years, 58% males), including 10 infants (20%), received modified subcoronary Ross/Ross–Konno operation at our institution. Survival, morbidity, reinterventions, aortic valve function and aortic root dimensions were analysed. RESULTS At a median follow-up of 31.2 months (range 14.4–51 months), there were 1 early death and 1 late death, both in the infant group. The overall survival at 5 years after the operation was 95%. Two patients needed aortic valve replacement, 11 and 15 months after their Ross operation. At 5 years, freedoms from reoperation on the autograft and on the right ventricle to pulmonary artery conduit were 94% and 97%, respectively. Freedom from aortic valve regurgitation greater than mild was 97% at 5 years. Median dimensions of the aortic root at all levels remained in normal range at last visit. Forty-four patients (95%) were in New York Heart Association class I with normal left ventricular function. CONCLUSIONS The initial experience with the subcoronary Ross/Ross–Konno operation in children and young adults showed excellent outcome. The mortality and morbidity among infants remain significant. The described technique is reproducible and might be advantageous in situations when prosthetic supporting techniques interfere with somatic growth. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Following the Ross operation, the pulmonary autograft undergoes structural changes (remodelling). We sought to determine the extent, nature and possible determinants of long-term remodelling in the different components of the pulmonary autograft. METHODS Ten pulmonary autografts and 12 normal control valves (6 pulmonary and 6 aortic) were examined by conventional histology, immunocytochemistry and electron microscopy. The structural changes were quantified by morphometry. RESULTS The leaflets from free-standing root replacement valves demonstrated thickening to levels comparable to the normal aortic leaflets, largely due to the addition of a thin layer of 'neointima' formed of radial elastic fibres, collagen bundles and glycoaminoglycans, on the ventricular aspect of the leaflets. The leaflets of valves from sub-coronary implantation demonstrated a significantly thicker fibroelastic layer on the ventricularis and calcium deposition in the fibrosa. The media of the explanted valves showed increased number of lamellar units to levels comparable to normal aortic roots. Electron microscopy of valves inserted as free-standing roots showed increased organization into continuous layers. However, intralamellar components showed varying degrees of 'disorganization' in comparison to those in the normal aortic media. In addition, there was a marked increase in the number of vasa vasorum with thickened arteriolar wall in the outer media and adventitia. CONCLUSIONS Following the Ross operation, in the very long term, all components of the autograft showed varying degrees of remodelling, which was judged to be largely adaptive. Defining the type, determinants and possible functional effects of remodelling could help in understanding and optimizing the results of the Ross operation. [ABSTRACT FROM AUTHOR]

Ross and Ross-Konno operations are associated with the inherent risk of residual ventricular septal dysfunction and injury to the conduction system. However, comprehensive biventricular functional outcomes on magnetic resonance imaging after Ross and Ross-Konno procedures are unknown. The purpose of this study was to evaluate and compare the degree of electrical and mechanical dyssynchrony using cardiac magnetic resonance imaging in patients late after Ross and Ross-Konno operations. Patients following Ross operation (n = 16), Ross-Konno operation (n = 13), and healthy controls (n = 12) underwent cardiac magnetic resonance imaging strain deformation analysis to quantify left ventricular (LV) intraventricular dyssynchrony and right ventricular (RV)–LV interventricular dyssynchrony. Mechanical dyssynchrony indices were correlated with the degree of electrical dyssynchrony as assessed by QRS duration, as well as with magnetic resonance imaging-derived biventricular and autograft regurgitation parameters. Patients in the Ross and Ross-Konno groups had reduced LV global longitudinal strain when compared with controls (both P values <.01). Both Ross (P <.05) and Ross-Konno (P <.01) groups demonstrated increased RV–LV interventricular dyssynchrony compared with controls. Patients in the Ross-Konno group also had increased septal LV intraventricular dyssynchrony when compared with control and Ross groups (both P values <.01). The global LV intramechanical dyssynchrony strongly correlated with QRS duration (R = 0.716; P <.001). There was no association between mechanical dyssynchrony and aortic regurgitation fraction. Long-term follow-up of patients who underwent Ross and Ross-Konno operations demonstrates reduced LV global longitudinal strain suggestive of chronically increased afterload independent of autograft function. Additionally, Ross-Konno operation is associated with impaired LV intraventricular mechanics and electrical dyssynchrony. [ABSTRACT FROM AUTHOR]

Aortic valve replacement is the gold standard for the management of patients with severe aortic stenosis or mixed pathology that is not amenable to repair according to currently available guidelines. Such a simplified approach may be suitable for many patients, but it is far from ideal for young adults considering emerging evidence demonstrating that conventional valve replacement in this cohort of patients is associated with inferior long-term survival when compared to the general population. Moreover; the utilisation of mechanical and bioprosthetic valves can significantly impact on quality and is linked to increased rates of morbidities. Other available options such as stentless valve, homografts, valve reconstruction and Ross operation can be an appealing alternative to conventional valve replacement. Young patients should be fully informed about all the options available - shared decision making is now part of modern informed consent. This can be achieved when referring physicians have a better understanding of the short and long term outcomes associated with every intervention, in terms of survival and quality of life. This review presents up to date evidence for available surgical options for young adults with aortic stenosis and mixed disease not amenable to repair.

OBJECTIVES The type of conduit used for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure remains problematic because of the limited availability of pulmonary allografts and the unsatisfactory long-term results associated with the use of xenografts. Polytetrafluoroethylene (PTFE) conduits have been proposed as an alternative. This study evaluated the results of RVOT reconstruction using a PTFE conduit during the Ross procedure. METHODS Between 2007 and 2015, 28 patients underwent RVOT reconstruction using PTFE conduits. The mean age of the patients was 35.9 ± 18.1 (range 4–58) years. The total root replacement technique was used in all patients. The mean PTFE conduit size was 25.3 ± 2.3 mm. RESULTS The early mortality rate was 3.6% (1 patient). The mean follow-up duration was 48.5 ± 31.2 months; there were no late deaths. The transprosthetic gradients increased significantly over time. The conduit size was the only independent predictor of peak RVOT gradient progression (P  = 0.02). None of the patients demonstrated significant RVOT regurgitation. One patient required an RVOT reoperation. CONCLUSIONS The PTFE conduit demonstrates acceptable haemodynamic results at the mid-term follow-up and could be considered as an alternative substitute for RVOT reconstruction during the Ross procedure. [ABSTRACT FROM AUTHOR]

Keywords: Ross operation; Valve sparing EN Ross operation Valve sparing 1 1 1 06/06/23 20230501 NES 230501 Recent reports [[1], [3]] showing the long-term benefit of the pulmonary autograft over conventional aortic valve (AV) replacement with a prosthesis in adults have renewed the interest in the Ross operation, which is regaining momentum. In cases of autograft dilatation, they employed mostly the root-remodelling technique with cusp repair and annular support by means of the suture annuloplasty, while in cases with isolated aortic regurgitation cusp repair did the job. [Extracted from the article]

OBJETIVO: Avaliar os resultados tardios de 10 anos com a operacão de Ross, analisando a sobrevida, incidência de reoperações e desempenho tardio do auto-enxerto pulmonar e homoenxerto da reconstrução da via de saída do ventrículo direito. MÉTODOS: Entre maio/1995 e fevereiro/2005, 227 pacientes com média de idade de 29,1±11 anos foram submetidos à operação de Ross. A etiologia prevalente foi a moléstia reumática em 61% dos casos. O auto-enxerto foi implantado com a técnica de substituição total da raiz em 202 casos, com cilindro intra-luminal em 20 e de forma subcoronariana em 5. A reconstrução da via de saída do ventrículo direito foi feita de forma convencional, com homoenxertos criopreservados (n= 160), com extensão proximal de pericárdio no homoenxerto (n= 41) e com homoenxertos decelularizados (n= 26). O tempo de seguimento pós-operatório variou de 1 - 118 meses ( média= 45,5 meses). RESULTADOS: A mortalidade imediata foi de 3,5% e a sobrevida tardia foi de 96,9%, aos 10 anos. Não houve episódio de tromboembolismo, constatando-se apenas dois casos de endocardite. Onze pacientes foram reoperados, por problemas envolvendo o auto e/ou homoenxerto, progressão de doença reumática mitral e insuficiência coronariana iatrogênica. Após 10 anos, 96,4% e 96,2% dos pacientes estavam livres de reoperação no auto-enxerto e no homoenxerto, respectivamente. Não foi observada dilatação tardia dos auto-enxertos.A reconstrução da via de saída do ventrículo direito com homoenxertos decelularizados diminuiu de forma significativa a incidência de gradientes tardios. CONCLUSÃO: Os resultados tardios com a operação de Ross demonstraram excelente sobrevida tardia e baixa incidência de reoperações e morbidade tardia. Consideramos este procedimento a melhor opção no tratamento cirúrgico da valvopatia aórtica em crianças e adultos jovens.OBJECTIVE: To evaluate the 10-year outcomes of the Ross Operation, analyzing survival rate, incidence of reoperations, and late performance of pulmonary autografts and homografts in the reconstruction of the right ventricular outflow tract. METHODS: Two hundred and twenty seven patients with a mean age of 29.1±11 years underwent Ross operation from May 1995 to February 2005. The most prevalent etiology was rheumatic disease in 61% of the cases. Autografts were implanted using the total root replacement technique in 202 cases, with intraluminal cylinder in 20, and in the subcoronary position in 5. The right ventricular outflow tract was conventionally reconstructed with cryopreserved homografts (n = 160), with proximal extension of the homograft with pericardium (n = 41), and with decellularized homografts (n = 26). The postoperative follow-up ranged from 1 to 118 months (mean = 45.5 months). RESULTS: Hospital mortality was 3.5%, and long-term survival was 96.9% at ten years. No episodes of thromboembolism and only two cases of endocarditis occurred. Eleven patients underwent reoperation because of problems related to the auto and/or homograft, progression of rheumatic mitral valve disease, and iatrogenic coronary insufficiency. After 10 years, 96.4% and 96.2% of the patients were free from reoperation in the autograft and homograft groups, respectively. No late autograft dilatation was observed. Reconstruction of the left ventricular outflow tract with decellularized homografts significantly reduced the incidence of gradients on late follow-up. CONCLUSION: Late outcomes with the Ross Operation were associated with an excellent long-term survival and a low incidence of reoperations and late morbidity. We consider this procedure the best option for the surgical treatment of aortic valve disease in children and young adults.

OBJECTIVES: Although the Ross procedure provides excellent long-term survival and a high quality of life, only a limited number of centres perform it as an alternative to the standard aortic valve replacement in adults. In the present study, we evaluated our 16-year results of using the Ross procedure in adult patients. METHODS: Between 1998 and 2014, 741 adult patients underwent the Ross procedure. The mean patient age was 47.4 ± 12.8 years (range, 18-67 years). The total root replacement technique was used in all patients. Right ventricular outflow tract (RVOT) reconstruction was performed with pulmonary allograft in 175 (23.6%) patients, with different types of xenografts in 561 (75.7%) and with polytetrafluoroethylene conduits in 5 (0.7%) patients. RESULTS: The early mortality rate was 3.0%. The mean follow-up duration was 5.8 ± 2.2 years. The survival rate at 10 years was 90.7% and was comparable with survival of an age- and sex-matched general population. The rate of freedom from autograft reoperations was 94.1 and 88.3% at 5 and 10 years, respectively. The aortic annulus dilatation was the only independent predictor of autograft failure. The 10-year freedom rates from reoperations for allograft, diepoxide- and glutaraldehyde-treated pericardial xenografts as well as porcine aortic root grafts were 100, 94.4, 82.7 and 80.6%, respectively. The use of xenografts and young patient age were associated with increased risk of RVOT conduit failure. CONCLUSIONS: The Ross operation provides long-term survival rates that are comparable with an age- and gender-matched general population. The dilated aortic annulus is a risk factor for late autograft valve insufficiency. A cryopreserved pulmonary homograft is the best option for RVOT reconstruction. Diepoxide-treated pericardial xenografts can be an alternative to allografts in elderly patients when an allograft is not available. [ABSTRACT FROM AUTHOR]

FUNDAMENTO: Em decorrência dos excelentes resultados tardios observados com a operação de Ross, sua utilização tem sido cada vez mais freqüente em vários Centros de todo o mundo. OBJETIVO: Relatar a experiência cirúrgica inicial com essa operação em nosso meio. CASUÍSTICA E MÉTODOS: De maio/95 a fevereiro/96,24 pacientes com média de idades de 28,3 anos foram submetidos à operação de Ross pelo método de substituição do segmento proximal da aorta ascendente. Para a reconstrução da via de saída do ventrículo direito, foram utilizados 17 homoenxertos pulmonares e 7 homoenxertos aórticos preservados em solução de antibióticos. Em todos os pacientes foram realizados ecocardiograma bidimensional com Doppler e cateterismo cardíaco no pós-operatório imediato, para avaliar a função ventricular e desempenho hemodinâmico dos auto e homoenxertos utilizados. Três pacientes com evolução clínica superior a seis meses realizaram novo ecocardiograma. RESULTADOS: A mortalidade hospitalar foi de 4%. Os sobreviventes tiveram alta hospitalar em ritmo sinusal e sem sopro diastólico de insuficiência aórtica. O desempenho hemodinâmico dos auto-enxertos foi muito satisfatório, com baixos gradientes de pico (4,0 ± 1,3 mmHg pelo ecocardiograma e 2,8 ± 1,2 mmHg pelo cateterismo). Vinte e um pacientes apresentaram auto-enxertos suficientes e/ou com insuficiência trivial, e 2 pacientes tiveram insuficiência leve. Nenhum paciente teve insuficiência moderada ou importante. Os gradientes de pico dos homoenxertos também foram baixos (3,0 ± 0,9 mmHg pelo ecocardiograma e 4,3 ± 1,4 mmHg pelo cateterismo) e apenas 2 apresentaram insuficiência leve. Houve significativa redução das dimensões sistólica e diastólica do ventrículo esquerdo no pós-operatório imediato, assim como da massa ventricular esquerda. Após um tempo médio de seguimento clínico de 5,1 meses (1-9 meses), todos os pacientes encontram-se em classe funcional I e livres de eventos. Três pacientes, com tempo de evolução superior a seis meses, realizaram ecocardiograma, que demonstrou normalização da função e massa ventricular, assim como manutenção do adequado desempenho hemodinâmico dos enxertos. CONCLUSÕES: A operação de Ross pode ser realizada em nosso meio com baixa mortalidade e resultados satisfatórios a curto prazo. Acreditamos que será amplamente empregada.BACKGROUND: After the excelent long term results reported with the Ross operation, its use increased worldwide. OBJECTIVE: Report our initial surgical experience with this procedure. METHODS: From may/95 trough february/96, 24 patients (mean age 28.3 years) were submitted to Ross procedure with the root replacement method. Reconstrution of the right ventricular outflow tract was achieved by 17 pulmonary and 7 aortic homografts stored in nutrient-antibiotic media. All patients were submitted to angiographic and echocardiographic Doppler flow studies at the immediate postoperative period to assess ventricular function and hemodynamic performance of the homografts. Three patients with follow-up longer than 6 months had a second ecocardiographic study. RESULTS: Hospital mortality was 4%. All hospital survivors were discharged in synus rhytm and with no diastolic murmur of aortic insufficiency. Hemodynamic performance of the autografts was excellent with low peak systolic gradients (4.0 ± 1.3 mmHg by echocardiography and 2.8 ± 1.2 mmHg by cardiac catheterism). Twenty-one patients had none or trivial autograft insufficiency and two presented with mild insufficiency. None had moderate or severe regurgitation. Peak systolic gradients in the homografts were also low (3.0 ± 0.9 mmHg by echocardiography and 4,3 ± 1,4 mmHg by catheterism) and only two had mild insufficiency. There was a significant reduction in left ventricular mass in the early postoperative period. After a mean follow-up of 5,1 months (1-9 months) all patients were in NYHA functional class I and free of events. Three patients with followup periods longerthan 6 months had asecond echocardiogram which showed normal left ventricular function and mass and adequate performance of the auto and homografts. CONCLUSION: The Ross operation can be done with low operative mortality and good short term results. We believe it will be widely employed by others in our country.

OBJECTIVES The ideal prosthesis for young patients requiring aortic valve replacement has not been defined to date. Although the Ross procedure provides excellent survival, its application is still limited. We compared the long-term survival after the Ross procedure with mechanical aortic valve replacement. METHODS All consecutive Ross procedures and mechanical aortic valve replacements performed between 1991 and 2008 at a single centre were analysed. Only adult patients between 18 and 50 years of age were included in the study. Survival and valve-related complications were evaluated. Furthermore, survival was compared with the age- and sex-matched Austrian population. RESULTS A total of 159 Ross patients and 173 mechanical valve patients were included. The cumulative survival for the Ross procedure was significantly better, with survival rates of 96, 94 and 93% at 5, 10 and 15 years, respectively, in comparison to 90, 84 and 75% (P < 0.01) for patients with mechanical valves. A Cox regression analysis including patients' age, gender and valve type revealed age and the type of aortic valve replacement as independent significant factors influencing survival (for age, hazard ratio = 1.1, 95% confidence interval = 1.0–1.1, P = 0.03; and for valve type, hazard ratio = 2.6, 95% confidence interval = 1.2–5.8, P = 0.02). The observed survival was comparable to the expected standard survival for the Ross group but was significantly reduced in the mechanical valve group. CONCLUSIONS In a real-world setting, the Ross procedure is associated with a long-term survival benefit in young adults in comparison to mechanical aortic valve replacement. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of this study was to evaluate the risk factors associated with Contegra graft (Medtronic Minneapolis, MN, USA) infection after reconstruction of the right ventricular outflow tract. METHODS One hundred and six Contegra grafts were implanted between April 1999 and April 2010 for the Ross procedure (n = 46), isolated pulmonary valve replacement (n = 32), tetralogy of Fallot (n = 24), double-outlet right ventricle (n = 7), troncus arteriosus (n = 4), switch operation (n = 1) and redo of pulmonary valve replacement (n = 2). The median age of the patients was 13 years (range 0–54 years). A follow-up was completed in all cases with a median duration of 7.6 years (range 1.7–12.7 years). RESULTS There were 3 cases of in-hospital mortality. The survival rate during 7 years was 95.7%. Despite the lifelong endocarditis prophylaxis, Contegra graft infection was diagnosed in 12 (11.3%) patients at a median time of 4.4 years (ranging from 0.4 to 8.7 years). Univariate analysis of preoperative, perioperative and postoperative variables was performed and the following risk factors for time to infection were identified: female gender with a hazard ratio (HR) of 0.19 (P = 0.042), systemic-to-pulmonary shunt (HR 6.46, P < 0.01), hypothermia (HR 0.79, P = 0.014), postoperative renal insufficiency (HR 11.97, P = 0.015) and implantation of permanent pacemaker during hospitalization (HR 5.29, P = 0.075). In 2 cases, conservative therapy was successful and, in 10 patients, replacement of the infected valve was performed. The Contegra graft was replaced by a homograft in 2 cases and by a new Contegra graft in 8 cases. Cox's proportional hazard model indicated that time to graft infection was significantly associated with tetralogy of Fallot (HR 0.06, P = 0.01), systemic-to-pulmonary shunt (HR 64.71, P < 0.01) and hypothermia (HR 0.77, P < 0.01). CONCLUSION Contegra graft infection affected 11.3% of cases in our cohort, and thus may be considered as a frequent entity that can be predicted by both intraoperative and early postoperative factors. After the diagnosis of infection associated with the Contegra graft was confirmed, surgical treatment was the therapy of choice. [ABSTRACT FROM AUTHOR]

The article presents a study which compares the maternal, fetal and cardiac outcomes in women who have undergone aortic valve replacement. Retrospective observational study was conducted on the women with aortic valve replacement, who underwent a pregnancy from 1998 to 2012. 32 pregnancies in 16 women divided into bioprosthetic, Ross and mechanical groups were evaluated. Presence of adverse maternal events in the bioprosthetic and Ross groups and three in the mechanical group was found.

Introduction: In the past 50 years, human cardiovascular tissue allografts, also called homografts, have been implanted into patients with different valvular diseases. The use of these allografts and the number of cardiovascular tissue banks and their respective techniques increased. We conducted a survey to establish the quantity of allografts processed, and issued by, European tissue banks. The survey also included the collection of other relevant statistics. Methods: In 2011, the Foundation of European Tissue Banks collected data from 19 different cardiovascular tissue banks in 11 European countries. Results: From 2007 to 2010 the data show a decrease in the number of hearts received, from 1700 to 1640 in 18 tissue banks; the average number of hearts received for cardiovascular tissue processing decreased from 113 to 91. The number of heart valves issued for transplantation increased from 1272 in 2007 to 1486 in 2010. The average rate of discard because of microbiological contamination was 20.7%, while 4.2% of the grafts were not used because of positive serology. Half of the tissue banks issued arterial grafts, while 3 banks also issued veins and pericardium. An overview of decontamination methods shows considerable methodological differences between 17 cardiovascular tissue banks. Conclusions: From the experience in Europe, it can be concluded that cardiovascular tissue banks have an established place in the domain of cardiovascular surgery. The statistics show fluctuating data concerning the demand for human cardiovascular allografts and methodological questions. There is room for growth and improvement with respect to validation of decontamination methods. [ABSTRACT FROM AUTHOR]

OBJECTIVE Autograft valve and root pathology is the leading cause of Ross procedure failure. To define risk and outcome of autograft valve/root repair at reoperation, a 17-year experience was analysed. METHODS One hundred and thirty-two consecutive late survivors underwent cross-sectional clinical and echocardiographic examination on average 10.8 ± 14.7 years (range 0.4–17) after Ross procedure. Study endpoints were hospital and late morbidity, freedom from autograft reoperation, freedom from root/valve replacement and functional outcome after valve/root repair. RESULTS Twenty-seven (20%) patients underwent 33 cardiac reoperations, the first on average 7.7 ± 4.5 years (range 0.08–16.2) after Ross operation. Nineteen had undergone root replacement, 5 inclusion cylinder and 3 subcoronary grafting. Indication was root pathology in 17 (63%) patients and isolated valve in 10. Surgery consisted in valve repair/sparing in 17 patients and valve/root replacement in 10, with no hospital mortality. Freedom from any autograft valve/root reoperation was 74 ± 5% at 15 years. No patient with valve/root replacement required second reoperation. Instead, 6/17 (35%) patients having autograft valve repair/sparing and followed for 4.2 ± 2.9 years (range 0.3–10.8) required re-repair/AVR, while 11 present mild AI or less. Freedom from autograft valve/root replacement was 83 ± 5% at 15 years. At multivariate analysis, predictors of reoperation were age at Ross (P = 0.002) and use of root technique (P = 0.049). Failure of autograft valve repair/sparing was associated with isolated valve pathology (P = 0.014) and earlier reoperation (P = 0.002). Pre-repair autograft insufficiency was significant at univariate analysis only (P = 0.01). CONCLUSIONS Autograft reoperation carries negligible hospital risk. Pulmonary valve sparing or repair is feasible in half of patients with Ross failure. Concomitant root remodelling and absence of preoperative severe valve dysfunction predict successful and durable repair. [ABSTRACT FROM AUTHOR]

OBJECTIVE Significant dilation of the pulmonary autograft is problematic after the Ross operation and may require reoperation. Pulmonary autograft remodelling occurs in response to the immediate rise in pressure and consequently wall stress. Stress–strain response of the pulmonary root plays an important role in understanding autograft function and remodelling following the Ross procedure. However, limited data are available on mechanical properties of fresh human pulmonary roots. The aim of this study was to compare mechanical properties of fresh human pulmonary and aortic roots prior to the Ross operation. METHODS Fresh healthy human hearts (n = 21) were obtained from California Transplant Donor Network (Oakland, CA, USA). Five regions of pulmonary and aortic roots, anterior and posterior artery and three sinuses, were subjected to displacement-controlled equibiaxial stretch testing within 24 h of cross-clamp time. Different regions of pulmonary and aortic roots were compared using a paired-comparison approach based on tissue stiffness at systemic pressure. Furthermore, histologic analysis was performed to compare the fibrous structure of pulmonary and aortic roots. RESULTS Human pulmonary and aortic roots demonstrated nonlinear response to biaxial loading in both circumferential and longitudinal directions. Pulmonary artery was found to be significantly stiffer than ascending aorta at systemic pressure in the two principal directions (P < 0.001). Similarly, pulmonary sinuses were significantly stiffer than the aortic sinuses at systemic pressure in the two directions (P < 0.001). Histological analysis revealed that aortic roots had tight denser weave of elastin than pulmonary roots. CONCLUSIONS Significant differences were found in the compliance and fibrous structure of human pulmonary and aortic roots. These regional differences may impact pulmonary autograft remodelling and influence late autograft dilation. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The Ross operation in the setting of a bicuspid aortic valve (BAV) remains controversial. Using data from the German Ross Registry, we sought to investigate the effect of the presence of a BAV on autograft function and diameters over time after the Ross operation compared with the presence of a tricuspid aortic valve (TAV). Methods: A total of 1277 patients (mean age 42.2±15.3 years) with intra-operatively documented aortic valve morphology during the Ross operation were analysed in the present study (sub-coronary technique, n =648, root replacement technique, n =629 patients). A BAV was present in 70.9% of patients. Clinical and echocardiographic follow-up was performed preoperatively and at pre-specified intervals (mean follow-up 5.7±3.8 years, 6806 patient-years). Hierarchical multilevel modelling techniques were used for the statistical analysis of serial measurements and comparisons among groups. Results: Initial neo-aortic regurgitation was lower in the BAV group (0.52 vs 0.62 aortic insufficiency (AI) grades, p =0.008), whereas the annual increase of it did not differ among groups. In both surgical techniques, no significant development of neo-aortic regurgitation (<0.02 AI grades per year) could be detected. Initial aortic annulus and sinus dimensions did not differ in the presence of a BAV. However, BAV patients developed a higher degree of annulus and sinus dilatation over time (0.20mm per year vs 0.06mm per year, p =0.003; 0.24 vs 0.11mm per year, p =0.013). This effect persisted when allowing for the two different surgical techniques. Baseline sinotubular junction (STJ) diameters did not differ among groups and annual increase thereof was similar (29.15mm vs 28.9mm, p =0.69; 0.44mm vs 0.35mm, p =0.15). Conclusions: For the observed time period, postoperative neo-aortic regurgitation after the Ross procedure did not differ between patients with a BAV or a TAV. Root dimensions, although clinically not relevant, increased in both valve entities supporting surgical reinforcement strategies. We cannot consider a BAV as a contraindication for the Ross operation. [Copyright &y& Elsevier]

Abstract: Background: For children who require aortic valve replacement, the pulmonary autograft may be the ideal substitute. However, re-operations for conduit exchange in the pulmonary position are inevitable. In addition, re-operations on the autograft may be necessary due to dilatation and neo-aortic insufficiency. We sought to assess predictors for re-intervention in an international Ross-operated paediatric population. Methods: Data of 152 children below 16 years of age at the time of the Ross operation were analysed using Cox proportional hazard modelling. Mean follow-up time was 6.1±4.2 years. Results: The median age at the time of the Ross operation was 10.1 years (range 54 days to 15 years). Early mortality was 2.6%. Survival at 5 and 10 years was 93.9±2.0% and 90.4±3.1%, respectively. Seven patients required autograft re-intervention (explantation n =6 and reconstruction n =1). Freedom from autograft re-intervention at 5 and 10 years was 99.3±0.7% and 95.5±2.7%, respectively. Prior endocarditis (p =0.061), prior aortic regurgitation (p =0.061) and longer follow-up time (p =0.036) emerged as risk factors for autograft re-intervention. Seventeen patients required 36 conduit re-interventions (replacement n =16, percutaneous valvuloplasty n =10). Freedom from conduit re-intervention at 5 and 10 years was 89.3±2.9% and 79.6±6.1%, respectively. Implantation of an aortic homograft (p =0.013), and smaller conduit size (p =0.074) emerged as risk factors for conduit re-intervention. Conclusions: There is a consistent need for conduit re-intervention following the Ross operation in children. Re-interventions on the autograft are rare within the first decade after surgery. However, the number of autograft re-interventions may increase after the first decade, since longer follow-up time is a risk factor for autograft failure. [Copyright &y& Elsevier]

Abstract: Objective: Following the Ross operation, pulmonary autografts tend to dilate over time. This study researches the fate of the pulmonary autograft – at 4.5 years following the modified Ross operation – with special reference to the impact of the modification on (a) pulmonary autograft dilatation, (b) the neo-aortic root geometry, (c) neo-aortic valve function and (d) the coronary artery reserve. Methods: A total of 26 patients who underwent the Ross operation were included in this study; of these, 13 consecutive patients underwent a modified Ross operation in which the free-standing autograft root was supported externally by a Dacron vascular prosthetic jacket (DVPJ). These patients were compared to a cohort of 13 matched patients who were operated on using the conventional Ross technique; all patients were followed up prospectively by echocardiography studies. The patients who underwent the modified Ross operation were also subjected to bicycle ergometry. Results: At the 47-month median follow-up, there was no significant increase in the size of the entire neo-aortic root in the patients who underwent the modified Ross operation; in addition, the geometry of the neo-aortic root was also preserved and the left ventricular function had improved significantly, whilst the aortic valve function and excursion remained satisfactory. All patients, with one exception, in the modified Ross operation group exhibited normal exercise capacity. By contrast, there were significant differences in diameters of the aortic root – between the two surgical techniques in favour of the modified Ross technique – following a median follow-up of 23 months in the patients subjected to the conventional Ross operation. Conclusions: Provision of external support to the entire pulmonary autograft with a DVPJ prevents its dilatation following free-standing pulmonary autograft Ross operation when evaluated at the 4.5-year follow-up. The function and the geometry of the neo-aortic root are not affected negatively by this modification and the patients demonstrated normal exercise capacity. [Copyright &y& Elsevier]

Abstract: Objective: To define the outcomes following Ross and Yasui procedures for complex biventricular repair of critical left ventricular outflow tract obstruction (LVOTO). Methods: Of 1217 neonates presenting with critical LVOTO enrolled in the Congenital Heart Surgeons Society studies (1994–2008), 52 underwent the Ross or Yasui procedure and their outcomes were investigated using univariate and multivariable parametric models. Results: ROSS (N =39): The Ross procedure (median age 87 days) was rarely the primary intervention (5/39, 13%). A significant number of cases were performed to treat iatrogenic aortic regurgitation after other previous interventions (25/39, 64%). Co-existing functional morphological defects were also common: 72% had preoperative evidence of mitral dysfunction, moderate-to-severe left ventricular dysfunction or endocardial fibroelastosis. Emergency iatrogenic aortic regurgitation (P =0.005) and co-existing abnormalities (mitral stenosis, P =0.02; mitral regurgitation, P =0.05; LV dysfunction, P =0.03) were strong determinants of death. Severe postoperative ventricular dysfunction or need for extracorporeal membrane oxygenation (ECMO) conferred negligible survival. Younger age was associated with disproportionately worse late outcome (5-year survival 44±10% for neonates vs 76±8% for age >3 months, P =0.0013). However, mitral and left ventricular dysfunction and emergency presentation were significantly more common in the younger age groups. Infants less than 3 months of age without co-existing abnormalities had acceptable late survival (≈75±20%). YASUI (N =13): Yasui repair (median age 22 days) was usually the primary intervention (nine of 13) but occasionally followed Norwood palliation (four of 13). None was an emergency. All had a ventricular septal defect. Survival was 69±13% at 10 years, which is not significantly different from other biventricular repair strategies in neonates. Aortic atresia was associated with better survival than stenosis (90±12% vs 30±14% at 3 years, P =0.039). None reverted to univentricular physiology later. Conclusions: Case selection is key for complex biventricular repair and the importance of appropriate case selection is exaggerated at young ages. All available options should be considered before pursuing the Ross operation in the presence of co-existing functional morphological abnormalities or emergent iatrogenic aortic regurgitation. However, both the Ross and Yasui operations in children (including neonates and young infants) with favourable functional morphology offer good survival, at least matching that of other biventricular repair strategies. [Copyright &y& Elsevier]

Abstract: Objective: To assess the results of aortic valve replacement with the pulmonary autograft in patients with rheumatic heart disease. Methods: From October 1993 through September 2003, 81 rheumatic patients with aortic valve disease, mean age 29.5±11.9 years (11–56 years) underwent, the Ross procedure with root replacement technique. Forty patients were 30 years of age or below (young rheumatics). Associated procedures included mitral valve repair (n =19), open mitral commissurotomy (n =15), tricuspid valve repair (n = 2), and homograft mitral valve replacement (n = 2). Results: Early mortality was 7.4% (six patients). Mean follow-up was 92.3±40.9 months (7–132 months, median 109 months). Sixty of the 73 patients whose follow-up was available (82%) had no significant aortic regurgitation. Re-operation was required in seven (8.4%) patients for autograft dysfunction with failed mitral valve repair (n = 3), autograft dysfunction alone (n = 2) and failed mitral valve repair alone (n = 2). No re-operations were required for the pulmonary homograft. There were six (7.5%) late deaths. Actuarial survival and re-operation-free survival at 109 months were 84.5±4.1% and 90.5±3.7%, respectively. Freedom from significant aortic stenosis or regurgitation was 78.4±5.2% and event-free survival was 64.6±5.8%. When compared to rheumatics above 30 years of age, the relative risk of autograft dysfunction was high in the young rheumatics. Conclusion: The Ross procedure is not suitable for young patients with rheumatic heart disease. However, it provides acceptable mid-term results in carefully selected older (>30 years) patients with isolated rheumatic aortic valve disease. [Copyright &y& Elsevier]

Objective: Structural differences of the pulmonary root may predispose it to progressive dilatation in the systemic circulation after the Ross operation. We identified the incidence and risk factors of pulmonary autograft root dilatation. Methods: One hundred and seven adult patients (mean age of 36±11 years) were followed after the Ross operation since 1991 including an echocardiogram within 3 months of surgery and yearly clinical assessment and echocardiography. The autograft was measured at the maximum diameter of the sinus (SV) and aortic insufficiency (AI) assessed. A SV of >37 mm was considered as root dilatation and the incidence over time was calculated using the Kaplan–Meier method. Clinically relevant dilatation was defined as a root diameter of >42 mm. In addition, we determined the percentage change of the sinus diameter between the early and latest echocardiogram. Furthermore we tested the influence of patient variables and risk factors on dilatation. Results: By 1 year, dilatation was found in 21 patients (20%). The SV was >42 mm in eight patients (7%). By 7 years, only 45% of patients were free of dilatation. Eleven patients (10%) had a SV of >42 mm. Increase in SV was time related and linear. However, 90% of patients showed <25% dilatation during follow-up. Time from operation, early SV diameter, male gender and surgical technique were identified as significant risk factors of dilatation. However, dilatation has not lead to reoperation due to aneurysm formation or development of significant AI. Conclusions: We conclude that time dependent autograft root dilation occurs but does not cause an increase in AI and need for reoperation up to 7 years. These findings warrant the pursuit of the concept of the Ross operation in young patients who regain excellent functional status and life style without anticoagulation. [Copyright &y& Elsevier]

Background: Reports on effectiveness and safety after the implant of pulmonary autograft (PA) living tissue in Ross procedure, to treat both congenital and acquired disease of the aortic valve and left ventricular outflow tract (LVOT), show variable durability results. We undertake a quantitative systematic review of evidence on outcome after the Ross procedure with the aim to improve insight into outcome and potential determinants., Methods: A systematic search of reports published from October 1979 to January 2021 was conducted (PubMed, Ovid Medline, Ovid Embase and Cochrane library) reporting outcomes after the Ross procedure in patients with diseased aortic valve with or without LVOT. Inclusion criteria were observational studies reporting on mortality and/or morbidity after autograft aortic valve or root replacement, completeness of follow-up >90%, and study size n≥30. Forty articles meeting the inclusion criteria were allocated to two categories: pediatric patient series and young adult patient series. Results were tabulated for a clearer presentation., Results: A total of 342 studies were evaluated of which forty studies were included in the final analysis as per the eligibility criteria. A total of 8,468 patients were included (7,796 in pediatric cohort and young adult series and 672 in pediatric series). Late mortality rates were remarkably low alongside similar age-matched mortality with the general population in young adults. There were differences in implantation techniques as regard the variability in stress and the somatic growth that recorded conflicting outcomes regarding the miniroot vs the subcoronary approach., Discussion: The adaptability of lung autograft to allow for both stress variability and somatic growth make it an ideal conduit for Ross's operation. The use of the miniroot technique over subcoronary implantation for better adaptability to withstand varying degrees of stress is perhaps more applicable to different patient subgroups., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-21-351/coif). FN serves as an unpaid editorial board member of Translational Pediatrics from March 2021 to February 2023. The other authors have no conflicts of interest to declare., (2022 Translational Pediatrics. All rights reserved.)

Se realiza una revisión de la historia de las prótesis cardíacas mecánicas y biológicas. Se conceptualizan los diferentes tipos de prótesis biológicas y se clasifican las diferentes válvulas mecánicas, según su estructura. Se presenta un resumen histórico sobre las diferentes especialidades que han participado en las construcciones de las válvulas cardíacas.A historical review of mechanical and biological cardiac prosthesis is made, conceptualizing the different mechanical valves according to its structure. This is a historical abstract on different specialties involving in cardiac valves constructions.

Background: Surgical treatment of young and middle-aged patients suffering from aortic valve disease remains an unresolved issue due to the limited durability of bioprosthetic heart valve replacements and the valve-related morbidity of patients with mechanical valve substitutes. Theoretically, the "living valve" principle of the Ross operation may represent a potentially viable solution to this dilemma. In this paper, we report on the surgical techniques of the Ross procedure and present long-term post-operative outcomes using the reinforced full-root technique., Methods: From 1995 to 2020, a total of 832 consecutive patients (mean age, 43.4±13.7 years; 617 males) underwent a Ross operation using the full-root technique. Patients were prospectively monitored with clinical and echocardiographic follow-up. Total follow-up was 9,046 patients-years and was 92% complete. Mean-follow-up was 10.9±6.9 years (range, 0-24.9 years)., Results: Survival at twenty years was 92% (95% CI: 90-94%). Freedom from autograft or right ventricle to pulmonary artery connection reoperation at twenty years was 79% (95% CI: 74-85%). Eighty-nine pulmonary autograft reoperations had to be performed in eighty patients; salvage of the pulmonary autograft could be performed in forty-six of them. Fifty-seven patients required sixty-three reoperations on the right ventricle to pulmonary artery connection. Major cerebral bleeding occurred in one patient and neurological events in seventeen patients, respectively., Conclusions: Over a follow-up interval of up to twenty-five years, the Ross operation with the reinforced full-root technique demonstrated excellent survival in young and middle-aged patients. The rate of pulmonary autograft and right ventricular outflow graft reoperations were low in this patient subset. Therefore, the Ross operation with the reinforced full-root technique represents an enduring and valid treatment option in young and middle-aged patients suffering from aortic valve disease., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2021 Annals of Cardiothoracic Surgery. All rights reserved.)

Abstract: We present our initial experience in 10 patients operated on using a modified Ross operation. In our modification of the Ross operation the pulmonary autograft root was inserted in the Gelweave Valsalva graft to prevent dilatation of the neoaortic root. This type of graft was selected to match the discrepancy between diameters of the annulus and the sinotubular junction of the autograft and to preserve the characteristic configuration of the native root. In our group of 10 patients operated consecutively by this technique there was no change in the geometry of the neoaortic root in the follow-up 3–19 months (mean 14.6 months). [Copyright &y& Elsevier]

It has been few years since the preliminary translational research study on mechanics performance of autologous pulmonary tissue were published to circumvent complication relies to SVD. Several studies reported the modification of pulmonary native autograft root subjected to dynamic stress strain in long-term outcomes of aortic valve replacement. Our multidisciplinary research team firstly describe the weave relationship between stress-strain, growth and remodelling in an experimental model of Ross Operation. From a biomechanical point of view, the rapid absorption of polydioxanone constituting the internal part of the device may limit the potential negative effect of excessive stretching and improvement of steeper curve in the circumferential response. Improvement of longitudinal stretching of pulmonary autograft by external component of device are indicative of auxetic effect of e-PTFE. Successful reinforcement with semiresorbable device can also be favourable to pulmonary autograft function in growing patients needing to match somatic growth. The attendant decrease in PA expansion and the preserved features of the valve leaflets enhances durability of Ross operation. Strengthening of the distal pulmonary root anastomosis using external reinforcement, modifying the ascending phase of the circumferential stress curve, might be advisable as previously described. PA is an ideal substitute for aortic valve replacement not only in Mr. Ross's dreams but also from the biomechanical point of view., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tp.2020.03.02). FN serves as the unpaid editorial board member of Translational Pediatrics from Feb 2019 to Jan 2021. The other authors have no conflicts of interest to declare., (2020 Translational Pediatrics. All rights reserved.)

The Ross Reversal operation is a breakthrough strategy first reported by Flynn et al. in 2007. In a reoperation for pulmonary autograft dysfunction after the Ross operation, an excised autograft can be preserved by reusing it in a native pulmonary position. We report a case wherein we used a new approach to excise the autograft valve with less invasion. The patient underwent a modified Ross Reversal operation concomitant with aortic root replacement and recovered without any complications. Our new approach enables a safer operation with improved valve function., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)