Risk Factors, Dynamics, and Cutoff Values for Homograft Stenosis After the Ross Procedure

doi:10.1016/j.athoracsur.2004.10.060

The Annals of Thoracic Surgery

Volume 79, Issue 5, May 2005, Pages 1669-1675

https://doi.org/10.1016/j.athoracsur.2004.10.060 Get rights and content

Background

The purpose of this study was to find homograft-related factors that might be associated with the development of stenosis after the Ross procedure, as well as to identify the natural dynamics of stenosis and find echographic cutoff values after one year of follow-up that might predict such an outcome.

Methods

We followed up 71 patients (mean age, 24.27 ± 16.57 years) who had such a procedure prospectively by transthoracic echocardiography, between 1993 and 2002. Follow-up was 55.26 ± 29.63 months and was 90.14% complete. Homografts were harvested from heart-beating donors or cardiac transplant recipients. Allograft stenosis was analyzed and risk factors were identified by univariate, multivariate, and survival analysis methods. Stenosis was defined as a mean gradient greater than or equal to 20 mm Hg.

Results

There were two reoperations and 21 homografts were stenotic at the last follow-up, ten of which were already so at one year after the procedure. Cox regression analysis revealed a transhomograft gradient greater than 9 mm Hg at 1 year after the procedure (hazard ratio [HR] = 10.04) and homograft size (HR = 0.75) as independent predictors for stenosis. Stenosis-free survival was 85.94 ± 4.35%, 75.51 ± 5.55%, and 68.56 ± 6.34 after 1, 3, and 5 years, respectively. A cutoff value of 9 mm Hg at 1 year of follow-up could predict different stenosis-free survival rates.

Conclusions

Homograft size is the most important homograft-related factor for stenosis. Most of the increase in transhomograft gradient occurs in the first 24 months. A gradient of 9 mm Hg or more after 1 year predicts the late occurrence of stenosis.

Section snippets

Patient Population

From February 1993 to November 2002 we performed 71 consecutive Ross procedures in the adult and pediatric cardiac surgery units of our institution. The median patient age was 23.97 years (range, 2 months–68 years). There were 15 female and 56 male patients. Their preoperative pathology and previous interventions are presented in Table 1. The study was approved by our institutional review board and informed consent was obtained from each patient included.

Operative Technique

The operative technique is described

Results

There were two reoperations in our cohort. One 20-year-old patient developed stenosis of his 24-mm pulmonary homograft 4 years after the Ross procedure, with dilation of his right ventricle. The cardiac angiography performed in the build-up to his reoperation revealed a calcified homograft on its anterior surface, with a stenosis that was localized close to the distal anastomosis. The diameter of the homograft measured at the level of the stenosis was 11 mm, while the internal diameter of the

Comment

Homografts have been used extensively over the last two decades to reconstruct the right ventricular outflow tract (RVOT). The development of cryopreservation as a method of tissue conservation has enabled longer storage and thus increased availability. Advantages over alternative conduits include ease of use [11] and natural hemodynamics. While homografts used as a pulmonary conduit in congenital heart diseases may be exposed to hemodynamic factors that may adversely affect their longevity

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Cited by (24)

Pulmonary homograft dysfunction after the Ross procedure using decellularized homografts—a multicenter study
2022, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Although homograft dysfunction appears to be an early complication following the Ross procedure, some patients might develop late stenosis or regurgitation. Previous studies have reported incidences of homograft dysfunction between 6% and 30% after 5 to 10 years of follow-up.6,8-11 In these studies, a similar temporal pattern was observed: the increase in pulmonary gradients occurs within the first 18 to 24 months after surgery and stabilizes thereafter, with a much lower rate of patients requiring reintervention on the pulmonary homograft, even after long-term follow-up.8,9,22
Pulmonary homograft dysfunction is a limitation after the Ross procedure. Decellularized pulmonary homografts can potentially mitigate this complication. The aim of this study was to examine the incidence, predictors, progression, and morphology of pulmonary homograft dysfunction using data from the Canadian Ross Registry.
From 2011 to 2019, 466 consecutive patients (mean age: 47 ± 12 years, 73% male) underwent a Ross procedure using a decellularized cryopreserved pulmonary homograft (SynerGraft SG; CryoKife, Kennesaw, Ga). Pulmonary homograft dysfunction was defined as any of the following: peak pulmonary gradient ≥30 mm Hg, pulmonary regurgitation >2, or pulmonary homograft reintervention. Patients meeting ≥1 of these criteria (n = 30) were compared with the rest of the cohort (n = 436). Median follow-up is 2.2 years (maximum = 8.5 years) and 99% complete (1176 patient-years).
The cumulative incidence of pulmonary homograft dysfunction was 11 ± 2% at 6 years. Pulmonary homograft stenosis was the most frequent presentation (n = 28 patients, 93%). Morphologically, stenosis occurred most often along the conduit (59%). Overall, 4 patients required homograft reintervention. At 6 years, the cumulative incidence of homograft reintervention was 3 ± 1%. The instantaneous risk was greatest in the first year after surgery (3.5%/year) and decreased to <1%/year thereafter. Patient age <45 years was the only independent risk factor associated with pulmonary homograft dysfunction (hazard ratio, 3.1, 95% confidence interval, 1.1-8.6, P = .03).
The use of decellularized cryopreserved pulmonary homografts results in a low incidence of dysfunction and reintervention after the Ross procedure. The risk is greater in the first postoperative year. Younger age is the only independent risk factor for pulmonary homograft dysfunction.
Transcatheter versus surgical valve replacement for a failed pulmonary homograft in the Ross population
2018, Journal of Thoracic and Cardiovascular Surgery
Patients who undergo the Ross procedure are at increased risk of pulmonary valve (PV) homograft dysfunction. For those who require reintervention on the homograft, transcatheter PV replacement (tPVR) provides a less invasive therapeutic option than surgical PVR (sPVR). We examined the outcomes following tPVR versus sPVR in a cohort of patients who underwent the Ross procedure.
We performed a retrospective analysis of Ross patients age ≥14 years who underwent tPVR (n = 47) or sPVR (n = 41) at our institution. The patients’ clinical and echocardiographic data were reviewed.
Baseline parameters, including demographic data and left ventricular and right ventricular (RV) systolic function, were similar in the 2 groups. The mean follow-up was 56 ± 24 months for the tPVR group and 89 ± 46 months for the sPVR group (P < .001). No procedure-related mortality was noted in either group. At 6-year follow-up, there was no significant between-group difference in event-free survival (tPVR, 79% ± 7% vs sPVR, 91% ± 4%; P = .15) or PV reintervention (tPVR, 26% ± 9% vs sPVR, 8% ± 5%; P = .31). PV-associated infective endocarditis (IE) was significantly more common with tPVR (tPVR, 13% vs sPVR, 0%; P = .04), with an annualized rate of 2.98% per patient-year. In addition, there was a trend toward more valve dysfunction following sPVR (sPVR, 67% ± 8% vs tPVR, 35% ± 8%; P = .08).
In Ross patients who require reintervention on the PV homograft, both tPVR and sPVR provide low procedural mortality and comparable midterm outcome with no significant difference in mortality or PV reintervention. However, IE is more common following tPVR. A larger randomized study is needed to determine the role of each procedure in patient management.
Reoperation after the ross procedure: Incidence, management, and survival
2012, Annals of Thoracic Surgery
Citation Excerpt :
Satisfactory short-term and midterm results have been demonstrated after the Ross operation, with low operative mortality and low rates of valve-related deaths or complications. As follow-up increased over the first decade, concern has been raised, however, about the growing number of patients who have required reoperation, and the Ross procedure is still controversial [11–18]. Early mortality in our series was 3.3%, and actuarial survival at 15 years was 93.3% (95% CI, 90.4% to 96.2%).
The risk of reoperation on the autograft and homograft is the major long-term drawback of the Ross procedure. The incidence and clinical implications of reoperations after the Ross procedure are reported.
Between March 1992 and February 2010, 336 consecutive patients had a Ross procedure (mean follow-up, 6.2 ± 4.9 years). Autograft implant technique was freestanding root replacement in 269 patients, subcoronary implantation in 52 patients and a modified root replacement with the autograft included in a Valsalva tube graft in 15.
Subsequently, 38 patients (11.3%) underwent reoperations, for autograft dilatation in 23 and a significant autograft insufficiency in 9, at 9.6 ± 3.7 years and 2.6 ± 3.9 years, respectively. Aortic and pulmonary infective endocarditis occurred in 3 patients. Three patients underwent a non valve-related cardiac reoperation. Three patients received a transcatheter pulmonary valve implantation after 12.2 ± 1.7 years. At 15 years, freedoms for autograft and homograft explantation (with 95% confidence interval) were 83.3% (77.4%- to 9.2%) and 92.8% (87.6% to 97.9%), respectively. Native aortic valve regurgitation, indexed aortic annulus diameter exceeding 1.35 cm/m² and autograft diameter were risk factors for dilated autograft reoperation (hazard ratio, 3.23 [95% confidence interval, 1.19 to 8.81], p = 0.02; 3.83 [0.9 to 16.33], p = 0.07 and 1.2 per mm [1.01 to 1.41], p = 0.03), respectively.
Autograft dilatation was the leading cause of reoperation in patients who underwent root replacement. Long-term follow-up is mandatory to determine whether modifications of the operative technique could limit autograft dilatation.
Discussion
2011, Annals of Thoracic Surgery
Citation Excerpt :
These authors suggested that the increased need for conduit replacement in younger patients may be due to the somatic growth of the children. Although others have also implicated patient age or homograft size as important determinants in the development of homograft stenosis, dysfunction, and the need for replacement [20, 21], some authors have not demonstrated a correlation between homograft size and need for reoperation [10, 22]. The study is limited by its retrospective design, relatively small patient population, and incomplete follow-up.
The optimal operation for aortic valve disease in children and young adults remains controversial. The Ross operation offers avoidance of anticoagulation and the potential for growth but is technically demanding and creates double-valve disease. The goal of this study is to report our experience with the Ross operation and the need for reintervention at intermediate follow-up.
A retrospective review of Ross operations in a single surgeon experience from 1992 to 2007 was conducted. All echocardiograms were reevaluated by a single cardiologist.
The cohort included 54 patients with a mean age of 13.5 years (range 0.5 to 35 years). Pulmonary autograft implantation was accomplished using root replacement (n = 43), root inclusion (n = 9), and Dacron tube root replacement (n = 2). Follow-up was available for 47 patients (87%) at a mean length of 6.4 years. There were no deaths. Kaplan-Meier estimates of freedom from explantation at 10 years were 100% for the autograft and 71% for the homograft. Autograft insufficiency at latest follow-up was trivial in 37 patients (82%), mild in 6 patients (13%), and moderate in 2 patients (4%). Reintervention for the homograft included balloon dilation in 3 children and conduit change in 5 children (all ≤ 2 years old at initial operation).
The Ross operation can be performed in children and adults with low mortality and can provide a durable result for the aortic valve with a low incidence of aortic insufficiency. The need for homograft replacement during follow-up in our series was primarily limited to children who were age 2 years or younger at initial operation.
The ross operation in children and young adults: A fifteen-year, single-institution experience
2011, Annals of Thoracic Surgery
Citation Excerpt :
These authors suggested that the increased need for conduit replacement in younger patients may be due to the somatic growth of the children. Although others have also implicated patient age or homograft size as important determinants in the development of homograft stenosis, dysfunction, and the need for replacement [20, 21], some authors have not demonstrated a correlation between homograft size and need for reoperation [10, 22]. The study is limited by its retrospective design, relatively small patient population, and incomplete follow-up.
The optimal operation for aortic valve disease in children and young adults remains controversial. The Ross operation offers avoidance of anticoagulation and the potential for growth but is technically demanding and creates double-valve disease. The goal of this study is to report our experience with the Ross operation and the need for reintervention at intermediate follow-up.
A retrospective review of Ross operations in a single surgeon experience from 1992 to 2007 was conducted. All echocardiograms were reevaluated by a single cardiologist.
The cohort included 54 patients with a mean age of 13.5 years (range 0.5 to 35 years). Pulmonary autograft implantation was accomplished using root replacement (n = 43), root inclusion (n = 9), and Dacron tube root replacement (n = 2). Follow-up was available for 47 patients (87%) at a mean length of 6.4 years. There were no deaths. Kaplan-Meier estimates of freedom from explantation at 10 years were 100% for the autograft and 71% for the homograft. Autograft insufficiency at latest follow-up was trivial in 37 patients (82%), mild in 6 patients (13%), and moderate in 2 patients (4%). Reintervention for the homograft included balloon dilation in 3 children and conduit change in 5 children (all ≤ 2 years old at initial operation).
The Ross operation can be performed in children and adults with low mortality and can provide a durable result for the aortic valve with a low incidence of aortic insufficiency. The need for homograft replacement during follow-up in our series was primarily limited to children who were age 2 years or younger at initial operation.
Performance of SynerGraft decellularized pulmonary homograft in patients undergoing a Ross procedure
2011, Annals of Thoracic Surgery
In the Ross aortic valve replacement (AVR), a pulmonary allograft normally replaces the autotransplanted pulmonary valve. Despite the Ross advantages vs other AVR procedures, there has been a small but unpredictable risk of early structural allograft valve deterioration, usually manifested by shrinkage and right ventricular outflow tract obstruction. This study analyzed our results of the Ross AVR using a new CryoValve SynerGraft (CryoLife Inc, Kennesaw, GA) decellularized pulmonary allograft (SGDPA) and compared it with the standard cryopreserved allograft (SCA) used during the same period.
Between 2000 and 2009, 29 patients received a SGDPA and 34 received the SCA during Ross AVR. Patients were a mean age at implant of 28.6 ± 16.0 years (range, 4 months to 58 years). Retrospective data included reported adverse events, and the most recent hemodynamic data were collected.
No early or late deaths or significant morbid events occurred during the mean follow-up of 4.9 ± 2.7 years (range, 2 months to 9 years). No patient required conduit reoperation. The median peak gradient at discharge was 12 mm Hg and was not significant at last follow-up. No deterioration in conduit valve function occurred in the SGDPA group. Mild conduit regurgitation developed in several SCA patients, and one patient had moderate regurgitation. No patient reached our definition of conduit dysfunction (peak gradient: 40 mm Hg or >2+ regurgitation).
The SGDPA conduit is an alternative to the SCA for the Ross AVR. The early clinical and hemodynamic results are encouraging but were not significantly different from the SCA. SynerGraft technology may provide a more durable option for patients who need right ventricular outflow tract reconstruction. Further long-term follow-up is needed to see if this decellularization process improves long-term allograft durability.

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Original articlesCardiovascularRisk Factors, Dynamics, and Cutoff Values for Homograft Stenosis After the Ross Procedure

Background

Methods

Results

Conclusions

Section snippets

Patient Population

Operative Technique

Results

Comment

Lancet

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

The pulmonary autograft—a permanent aortic valve

Eur J Cardiothorac Surg

Original articles
Cardiovascular
Risk Factors, Dynamics, and Cutoff Values for Homograft Stenosis After the Ross Procedure