Re:The role of Left Ventricle in the Autograft Complication after ROSS operation

Giovanni Battista Luciani, Professor and Head,
October 28, 2014

We thank the Authors for the careful analysis of our work and the kind comments. In general, a distinction needs to be made when analysing clinical outcome after the Ross procedure in paediatric age. Whereas the neonatal and infant population generally presents with either isolated (often recurrent) or complex, multilevel LVOTO, which may be associated with mitral valve disease and varying degrees of LV hypoplasia, the preschool and school age population generally requires the Ross procedure for isolated (congenital) aortic valve disease. Therefore, the former patient subgroup is characterized by high operative risk and reoperations on the left heart mostly due to technical (autograft) or concomitant (mitral, aortic arch) problems. On the contrary, in the latter group, hospital risk is negligible (less than 1%) and reintervention is generally caused by progressive autograft root dilation and/or dysfunction. In other words, the pre-school and school age child having the Ross procedure tends to behave similar to the grown-up or adult, as previously shown by Hazekamp and associates [1]. Practically, the concern raised by Li and colleagues applies only to older children. Indeed, in one of our previous works [2], as well as in the study by Horer and associates [3], attention was mostly focused on the older child and the young adult, as the infant population was modestly represented. Thus, differences in baseline demography (particularly mean age) might perhaps explain, at least in part, the apparent contradictory results of the multivariate analysis amongst different studies. In fact, we essentially agree with the point raised by the Authors, as in the older child and the grown-up presenting with aortic insufficiency, LV and anular dilation, recurrence or non regression of LV dilation after the Ross procedure may promote late autograft dilation and dysfunction. We regret not to be able to further support this hypothesis in the Italian Paediatric Ross Registry database [4] due to incompleteness of echocardiographic follow-up information.


1. Hazekamp MG, Grotenhuis HB, Schoof PH, et al. Results of the Ross operation in a pediatric population. Eur J Cardiothorac Surg. 2005 Jun;27(6):975-9.

2. Luciani GB, Favaro A, Casali G, et al. Ross operation in the young: a ten-year experience. Ann Thorac Surg 2005;80:2271-7.

3. Horer J, Kasnar-Samprec J, Charitos E, et al. Patient age at the Ross operation in children influences aortic root dimensions and aortic regurgitation. World J Pediatr Congenit Heart Surg 2013;4:245-52.

4. Luciani GB, Lucchese G, Carotti A, et al. Two decades of experience with the Ross operation in neonates, infants and children from the Italian Paediatric Ross Registry. Heart 2014 0:heartjnl-2014-305873v1- heartjnl-2014-305873; doi:10.1136/heartjnl-2014-305873

Conflict of Interest:

None declared

Conflict of Interest

None declared