Re-interventions after the Ross procedure: reasons, technical approaches, immediate outcomes

Abstract

Re-interventions after pulmonary autograft aortic valve replacement (Ross procedure) may be associated with dysfunction of the neoaortic, neopulmonary, or both operated valves. Late dysfunction, other than infective endocarditis, is associated with underlying conditions, technical errors, and unsuitable pulmonary trunk replacement materials. Re-interventions are technically complex, while tactical approaches have not been definitively formulated. Objective: to analyze re-interventions in patients after Ross procedure, technical approaches and immediate outcomes. Material and methods. Between 2001 and 2019, 14 patients were reoperated upon within 2 days to 21 years after primary Ross procedure. Early prosthetic endocarditis (2) and technical errors (1) were the reasons for early postoperative re-intervention. Neoaortic valve insufficiency (7), including pulmonary valve dysfunction (2), pulmonary valve degeneration (2), pulmonary prosthetic valve endocarditis (1), aortic, pulmonary and mitral valve endocarditis (1) were the reasons for late postoperative re-intervention. Based on the lesion volume, neoaortic valve replacement (3), neoaortic root replacement (6), including pulmonary valve/trunk replacement (8), and pulmonary trunk stenting (2) were performed. Results. In-hospital mortality was 7.1%. One patient died of early endocarditis after primary procedure. The postoperative period for the remaining patients was uneventful. Microscopic examination of the neoaorta revealed fragmentation of elastic fibers and rearrangement of tissue histoarchitectonics. In the pulmonary position, the aortic allograft and stentless xenograft had severe calcification and valve stenosis. Conclusions. Neoaortic valve insufficiency associated with cusp prolapse and neoaortic root dilatation may be the reasons for re-interventions after the Ross procedure. The second reason for re-interventions is valve graft dysfunction in the pulmonary trunk position. Elective reoperations on the neoaortic root and/or lung graft, despite the large volume, can be performed with low mortality and morbidity. Aortic allografts and xenografts for reconstruction of the right ventricular outflow tract (RVOT) is unjustified due to early and more severe dysfunction compared to pulmonary allograft.