Technical evolution of the Ross operation: midterm results in 186 patients.

Background: The Ross operation approaches the ideal aortic valve replacement. Between February 1995 and February 2000 we performed 186 procedures. This article reviews modifications introduced reflecting our experience.
Methods: In all patients the Ross operation was performed as root replacement. Echocardiographic follow-up was complete in 94% of patients.
Results: No operative death or early mortality occurred, nor did thromboembolic or hemorrhagic events. One patient died at 25 months from hemoptysis with pulmonary valve vegetations. Three patients required reoperation for autograft insufficiency. In 1 patient a tethered cusp was repairable and in 2 patients progressive autograft dilatation required autograft replacement. After routinely incorporating support into the aortic annulus and replacing all dilated ascending aorta, autograft dilatation did not recur. For the pulmonary homograft, one outflow patch was placed to relieve a symptomatic gradient. Nine patients with elevated gradients were under observation. Echocardiography revealed autograft median peak systolic gradients of 4.6+/-2.8 mm Hg, pulmonary homograft gradients of 14.8+/-9.6 mm Hg, and nil or insignificant regurgitation.
Conclusions: The aortic annulus must be supported and the dilated ascending aorta replaced. Root replacement with a short autograft allows consistent results. Pulmonary homograft dysfunction is rare but unpredictable.