Tailoring the Ross procedure for patients with aortic regurgitation
Amine Mazine, Ismaı̈l El-Hamamsy
Abstract
Central MessageWith proper technical refinements and strict postoperative blood pressure control, the Ross procedure is an excellent operation for treating nonrepairable aortic regurgitation in young adults.See Commentaries on pages 390, 392, and 394. With proper technical refinements and strict postoperative blood pressure control, the Ross procedure is an excellent operation for treating nonrepairable aortic regurgitation in young adults. See Commentaries on pages 390, 392, and 394. Aortic valve repair and aortic valve-sparing operations represent the best options to treat aortic regurgitation (AR) in nonelderly adults.1Antoniou A. Harky A. Bashir M. El Khoury G. Why I choose to repair and not to replace the aortic valve?.Gen Thorac Cardiovasc Surg. 2019; 67: 20-24Crossref PubMed Scopus (8) Google Scholar,2Baumgartner H. Falk V. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Crossref PubMed Scopus (2) Google Scholar When performed by expert surgeons, these operations are safe and result in good durability and freedom from valve-related complications, leading to excellent long-term survival.3David T.E. Aortic valve repair and aortic valve-sparing operations.J Thorac Cardiovasc Surg. 2015; 149: 9-11Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,4Schneider U. Hofmann C. Schöpe J. Niewald A.K. Giebels C. Karliova I. et al.Long-term results of differentiated anatomic reconstruction of bicuspid aortic valves.JAMA Cardiol. 2020; 5: 1366-1373Crossref PubMed Scopus (18) Google Scholar When the aortic valve cannot be repaired or spared, valve replacement becomes essential. The vast majority of patients who undergo aortic valve replacement (AVR) will receive a bioprosthetic or mechanical valve. Numerous large studies have demonstrated that nonelderly adults who receive prosthetic valves—be they biological or mechanical—have a survival disadvantage compared with the age- and sex-matched general population.5Bouhout I. Stevens L.M. Mazine A. Poirier N. Cartier R. Demers P. et al.Long-term outcomes after elective isolated mechanical aortic valve replacement in young adults.J Thorac Cardiovasc Surg. 2014; 148: 1341-1346.e1Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar,6Bourguignon T. Bouquiaux-Stablo A.L. Candolfi P. Mirza A. Loardi C. 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Lagazzi L. Thomas J. et al.Survival after valve replacement for aortic stenosis: implications for decision making.J Thorac Cardiovasc Surg. 2008; 135 (discussion 1278-9): 1270-1278Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar In recent years, increasing recognition of the suboptimal outcomes of prosthetic AVR in young and middle-aged adults has led to a resurgence of interest in the Ross procedure.10Bonow R.O. Resurgence of the Ross procedure.Ann Cardiothorac Surg. December 23, 2020; ([Epub ahead of print])Google Scholar First described by Donald Ross in 1967,11Ross D.N. Replacement of aortic and mitral valves with a pulmonary autograft.Lancet. 1967; 2: 956-958Abstract PubMed Google Scholar the Ross procedure is the only replacement operation that allows for long-term viability of the aortic root. Owing to its unique biological and hemodynamic properties, the Ross procedure is an attractive option for nonelderly adults undergoing AVR. In expert centers, it carries a similar operative risk as conventional AVR12Bouhout I. Noly P.E. Ghoneim A. Stevens L.M. Cartier R. Poirier N. et al.Is the Ross procedure a riskier operation? Perioperative outcome comparison with mechanical aortic valve replacement in a propensity-matched cohort.Interact Cardiovasc Thorac Surg. 2017; 24: 41-47Crossref PubMed Scopus (26) Google Scholar and is associated with low rates of valve-related complications, excellent quality of life, and long-term survival equivalent to that of the age- and sex-matched general population.13Mazine A. El-Hamamsy I. Verma S. Peterson M.D. Bonow R.O. Yacoub M.H. et al.Ross procedure in adults for cardiologists and cardiac surgeons: JACC state-of-the-art review.J Am Coll Cardiol. 2018; 72: 2761-2777Crossref PubMed Scopus (69) Google Scholar In addition, several recent publications have demonstrated that in appropriately selected patients, the Ross procedure provides superior outcomes compared with prosthetic AVR.14Buratto E. Shi W.Y. Wynne R. Poh C.L. Larobina M. O'Keefe M. et al.Improved survival after the Ross procedure compared with mechanical aortic valve replacement.J Am Coll Cardiol. 2018; 71: 1337-1344Crossref PubMed Scopus (65) Google Scholar, 15El-Hamamsy I. Eryigit Z. Stevens L.M. Sarang Z. George R. Clark L. et al.Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial.Lancet. 2010; 376: 524-531Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar, 16Mazine A. David T.E. Rao V. Hickey E.J. Christie S. Manlhiot C. et al.Long-term outcomes of the ross procedure versus mechanical aortic valve replacement: propensity-matched cohort study.Circulation. 2016; 134: 576-585Crossref PubMed Scopus (80) Google Scholar, 17Sharabiani M.T. Dorobantu D.M. Mahani A.S. Turner M. Peter Tometzki A.J. Angelini G.D. et al.Aortic valve replacement and the Ross operation in children and young adults.J Am Coll Cardiol. 2016; 67: 2858-2870Crossref PubMed Scopus (87) Google Scholar As a result of this growing body of evidence, many experts now view the Ross procedure as the best operation to treat aortic stenosis (AS) in young and middle-aged adults.18Misfeld M. Borger M.A. The Ross procedure: time to reevaluate the guidelines.J Thorac Cardiovasc Surg. 2019; 157: 211-212Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,19Ouzounian M. Mazine A. David T.E. The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults.J Thorac Cardiovasc Surg. 2017; 154: 778-782Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar However, its use in patients presenting with AR remains a matter of debate. This is due to a higher risk of pulmonary autograft dilatation—and subsequent need for reintervention—in these patients. Indeed, several studies have consistently indicated an association between the presence of preoperative AR—particularly in the setting of a dilated aortic annulus—and an increased risk of reintervention.20Charitos E.I. Takkenberg J.J. Hanke T. Gorski A. Botha C. Franke U. et al.Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: an update on the German Dutch Ross Registry.J Thorac Cardiovasc Surg. 2012; 144 (discussion 821-3): 813-821Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 21da Costa F.D. Takkenberg J.J. Fornazari D. Balbi Filho E.M. Colatusso C. Mokhles M.M. et al.Long-term results of the Ross operation: an 18-year single institutional experience.Eur J Cardiothorac Surg. 2014; 46 (discussion 422): 415-422Crossref PubMed Scopus (50) Google Scholar, 22David T.E. David C. Woo A. Manlhiot C. The Ross procedure: outcomes at 20 years.J Thorac Cardiovasc Surg. 2014; 147: 85-93Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 23David T.E. Ouzounian M. David C.M. Lafreniere-Roula M. Manlhiot C. Late results of the Ross procedure.J Thorac Cardiovasc Surg. 2019; 157: 201-208Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 24David T.E. Woo A. Armstrong S. Maganti M. When is the Ross operation a good option to treat aortic valve disease?.J Thorac Cardiovasc Surg. 2010; 139 (discussion 73-5): 68-73Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 25Martin E. Mohammadi S. Jacques F. Kalavrouziotis D. Voisine P. Doyle D. et al.Clinical outcomes following the Ross procedure in adults: a 25-year longitudinal study.J Am Coll Cardiol. 2017; 70: 1890-1899Crossref PubMed Scopus (50) Google Scholar, 26Ryan W.H. Prince S.L. Culica D. Herbert M.A. The Ross procedure performed for aortic insufficiency is associated with increased autograft reoperation.Ann Thorac Surg. 2011; 91 (discussion 69-70): 64-69Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 27Weimar T. Charitos E.I. Liebrich M. Roser D. Tzanavaros I. Doll N. et al.Quo vadis pulmonary autograft--the Ross procedure in its second decade: a single-center experience in 645 patients.Ann Thorac Surg. 2014; 97: 167-174Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar As a result, many advocate against using the Ross procedure in the setting of AR. For instance, the 2013 Society of Thoracic Surgeons guidelines allocate a class III recommendation for the Ross procedure in patients with bicuspid aortic valve (BAV) and AR.28Svensson L.G. Adams D.H. Bonow R.O. Kouchoukos N.T. Miller D.C. O'Gara P.T. et al.Aortic valve and ascending aorta guidelines for management and quality measures.Ann Thorac Surg. 2013; 95: S1-S66Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Nevertheless, a careful examination of the data suggests otherwise. On the one hand, despite a higher reintervention hazard, the late survival benefit observed with the Ross procedure in AS is preserved in patients with AR. On the other hand, it has become apparent that the risk of reintervention can be mitigated by adapting the surgical technique and adjusting postoperative blood pressure management. Herein we review the contemporary evidence surrounding the use of the Ross procedure in patients with AR and describe the technical and medical modifications that make the Ross procedure the best operation to treat young adults with nonrepairable AR. Compared with patients who undergo surgery for AS, those who undergo surgery for AR tend to present at a younger age and have higher rates of congenital aortic valve anomalies (ie, bicuspid, unicuspid, or quadricuspid aortic valves), dilated aortic annuli, ascending aortic aneurysm, and size mismatch between the pulmonary and aortic roots. As a result of these factors, various clinical studies have demonstrated that patients undergoing the Ross procedure for AR are at greater risk of autograft dilatation and reoperation than those with AS. These studies are summarized in Table 1. Although a detailed review of these individual reports falls beyond the scope of this article, it should be noted that in most of these studies, the root replacement technique was heavily favored, and in most cases, no effective systematic root stabilization strategies or blood pressure control protocols were in place for patients with AR. Furthermore, none of the studies showed different long-term survival rates between the AS and AR groups. In other terms, the main benefit of the Ross procedure—preserved survival, which is predicated on the unique biologic and hemodynamic properties of the living pulmonary autograft—is preserved. Given this, rather than abandoning the Ross procedure, the question becomes "how can we improve durability in patients with AR"?Table 1Summary of studies comparing outcomes of the Ross procedure in adults with AS versus ARStudyPatients, nMean age, yBAV/UAV/QAV, %∗Percentage of patients in the cohort who presented with a bicuspid, unicuspid, or quadricuspid valve.AS/AR mixed AS-AR, %Surgical techniqueAnnuloplasty, %Annuloplasty typeMean follow-up, yFreedom from autograft reoperationDavid et al. (2010)24David T.E. Woo A. Armstrong S. Maganti M. When is the Ross operation a good option to treat aortic valve disease?.J Thorac Cardiovasc Surg. 2010; 139 (discussion 73-5): 68-73Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar21234 ± 98250/36/13RR (51%),SC/inclusion (49%)46Subcommissural plication and partial Dacron strip10.1 ± 4.2At 15 y:AS, 97%AR, 84%Weimar et al. (2014)27Weimar T. Charitos E.I. Liebrich M. Roser D. Tzanavaros I. Doll N. et al.Quo vadis pulmonary autograft--the Ross procedure in its second decade: a single-center experience in 645 patients.Ann Thorac Surg. 2014; 97: 167-174Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar64542 ± 145832/29/33RR (98%), SC (2%)63Dacron strip8.4 ± 4.6At 10 y:AS, 97%AR, 90%Skillington et al. (2015)29Skillington P.D. Mokhles M.M. Takkenberg J.J. Larobina M. O'Keefe M. Wynne R. et al.The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.J Thorac Cardiovasc Surg. 2015; 149: S46-S52Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar32240 (range 15-63)9546/32/22Inclusion (100%)62Circumferential ring (5%), partial ring (30%), partial ring and annular plication (25%), annular plication (2%)9.8At 18 y:96% overallAS, n = 1AR, n = 9AS/AR, n = 1Mastrobuoni et al. (2016)30Mastrobuoni S. de Kerchove L. Solari S. Astarci P. Poncelet A. Noirhomme P. et al.The Ross procedure in young adults: over 20 years of experience in our institution.Eur J Cardiothorac Surg. 2016; 49 (discussion 512-3): 507-512Crossref PubMed Scopus (52) Google Scholar30642 ± 105968/31/0SC (2%), RR (55%), inclusion (43%)N/AN/A10.6At 16 y:AS, 83%AR, 65%Charitos et al. (2012)20Charitos E.I. Takkenberg J.J. Hanke T. Gorski A. Botha C. Franke U. et al.Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: an update on the German Dutch Ross Registry.J Thorac Cardiovasc Surg. 2012; 144 (discussion 821-3): 813-821Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar176044 ± 127124/23/51SC (44%), RR (56%)35N/A7.1 ± 4.6HR (AR vs AS), 2.3 (95% CI, 1.5-3.5); P <.001Da Costa et al. (2014)21da Costa F.D. Takkenberg J.J. Fornazari D. Balbi Filho E.M. Colatusso C. Mokhles M.M. et al.Long-term results of the Ross operation: an 18-year single institutional experience.Eur J Cardiothorac Surg. 2014; 46 (discussion 422): 415-422Crossref PubMed Scopus (50) Google Scholar41431 ± 135029/39/31RR (86%), inclusion (14%)7External strip of Dacron/pericardium8.2 ± 5.2At 15 y: 91% overallMartin et al. (2017)25Martin E. Mohammadi S. Jacques F. Kalavrouziotis D. Voisine P. Doyle D. et al.Clinical outcomes following the Ross procedure in adults: a 25-year longitudinal study.J Am Coll Cardiol. 2017; 70: 1890-1899Crossref PubMed Scopus (50) Google Scholar31041 ± 117873/19/7RR (84%), inclusion (11%), SC (6%)1N/A15.1 (IQR, 5.5-18.4)HR (AR vs AS), 2.7 (95% CI, 1.4-5.1);P = .002Ryan et al. (2011)26Ryan W.H. Prince S.L. Culica D. Herbert M.A. The Ross procedure performed for aortic insufficiency is associated with increased autograft reoperation.Ann Thorac Surg. 2011; 91 (discussion 69-70): 64-69Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar16042 ± 118742/58/0RR38Circumferential suture annuloplastyAS, 4.5 ± 2.9; AR, 6.0 ± 3.2At 10 y: AS, 95 ± 5%; AR, 67 ± 9%BAV, Bicuspid aortic valve; UAV, unicuspid aortic valve; QAV, quadricuspid aortic valve; AS, aortic stenosis; AR, aortic regurgitation; RR, root replacement; SC, subcoronary; N/A, not available; HR, hazard ratio; CI, confidence interval; IQR, interquartile range.∗ Percentage of patients in the cohort who presented with a bicuspid, unicuspid, or quadricuspid valve. Open table in a new tab BAV, Bicuspid aortic valve; UAV, unicuspid aortic valve; QAV, quadricuspid aortic valve; AS, aortic stenosis; AR, aortic regurgitation; RR, root replacement; SC, subcoronary; N/A, not available; HR, hazard ratio; CI, confidence interval; IQR, interquartile range. In the following sections, we examine the potential causes of the association between AR and premature autograft failure and ask whether they can be addressed at the time of surgery and in the early postoperative period. Furthermore, given that reoperation is only one of many important metrics to consider when evaluating the outcomes of valve surgery in young patients, we put these results in their broader context and examine the impact of preoperative AR on other critical endpoints, such as survival and quality of life. Although the association between preoperative AR and postoperative autograft dilatation has been clearly established, the underlying pathophysiology remains incompletely understood. It has been proposed—with little supportive evidence—that the presence of AR and a dilated aortic annulus may be a surrogate for genetic disease of the semilunar valves and great arterial walls, and that this genetic abnormality may impair adaptive remodeling of the pulmonary autograft, leading to early dilatation and failure. Indeed, following its implantation in the aortic position, the pulmonary autograft—which is a living structure—adapts and remodels in response to the drastic change in hemodynamic conditions compared with its native position within the pulmonary circulation. It has been suggested that a proportion of patients who present with AR and a dilated aortic annulus may have an unrecognized genetic vascular anomaly that impairs this process. This "genetic" hypothesis is supported by the observation in some series that surgical maneuvers aimed at stabilizing the aortic annulus in the hope of preventing autograft dilatation appear to be ineffective in these patients. Indeed, early on in their experience with the Ross procedure, David and colleagues31David T.E. Omran A. Webb G. Rakowski H. Armstrong S. Sun Z. Geometric mismatch of the aortic and pulmonary roots causes aortic insufficiency after the Ross procedure.J Thorac Cardiovasc Surg. 1996; 112 (discussion 1237-9): 1231-1237Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar recognized that the aortic and pulmonary roots often had a size mismatch in patients with AR, and that this was a cause of early autograft failure. Following this observation, the authors began to systematically adjust the size of the aortic annulus before autograft implantation whenever such a mismatch was present. This was achieved by way of subcommissural plication of the noncoronary sinus and partial annuloplasty with a Dacron strip. Importantly, this partial annuloplasty was performed along the fibrous portion of the left ventricular outflow tract. These maneuvers were effective in preventing early autograft dilatation and AR but did not prevent late autograft failure, leading the authors to conclude that AR and a dilated aortic annulus portend premature autograft failure that cannot be curtailed surgically.24David T.E. Woo A. Armstrong S. Maganti M. When is the Ross operation a good option to treat aortic valve disease?.J Thorac Cardiovasc Surg. 2010; 139 (discussion 73-5): 68-73Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Several observations argue against this genetic hypothesis, however. First, that subcommissural plication did not prevent autograft dilatation should come as no surprise, as this technique has also proven ineffective in the context of aortic valve repair.32de Meester C. Vanovershelde J.L. Jahanyar J. Tamer S. Mastrobuoni S. Van Dyck M. et al.Long-term durability of bicuspid aortic valve repair: a comparison of 2 annuloplasty techniques.Eur J Cardiothorac Surg. January 25, 2021; ([Epub ahead of print])Crossref PubMed Scopus (4) Google Scholar This is because in AR, dilatation occurs mainly at the level of the muscular, rather than fibrous, portion of the annulus, an issue not addressed with subcommissural stitches or a Dacron strip along the aorto-mitral curtain. Second, none of the studies describing an association between preoperative AR and early autograft failure have reported the use of a strict postoperative blood pressure control regimen. Third, studies have shown that in patients who suffer postoperative autograft dilatation and failure, most of the dilatation is incurred by hospital that technical be at Takkenberg J.J. A.J. pulmonary autograft dilatation causes important aortic PubMed Scopus Google Scholar recent cardiac studies have shown that when using a the of patients presenting with AR similar and at after the Ross procedure as in patients presenting with M. A. I. Poirier N. M. El-Hamamsy I. et remodeling after the Ross procedure by aortic stenosis versus Thorac Cardiovasc Surg. 2020; ([Epub ahead of Full Text Full Text PDF PubMed Scopus (4) Google Scholar These that the the pulmonary root of patients with AR is of the adaptive remodeling as that of patients with AS. these that with proper to the surgical technique and postoperative excellent results can be achieved with the Ross procedure in patients with AR. In the we review strategies that have been to improve the durability of the Ross operation in these patients. Several strategies have been to the risk of early autograft dilatation and failure in patients with AR. these strategies in support to the autograft and strict postoperative blood pressure The most and autologous support of the autograft using the aortic root in the technique P.D. Mokhles M.M. Takkenberg J.J. Larobina M. O'Keefe M. Wynne R. et al.The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.J Thorac Cardiovasc Surg. 2015; 149: S46-S52Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar support of the autograft using a prosthetic Dacron T. A. clinical and after pulmonary autograft Ross Thorac Cardiovasc 2016; Full Text Full Text PDF PubMed Scopus Google Scholar and a surgical I. Ghoneim A. M. Stevens L.M. T. M. et of a surgical on autograft root in patients undergoing the Ross procedure for aortic J Cardiothorac Surg. 2019; PubMed Scopus Google A. Ghoneim A. El-Hamamsy I. The Ross procedure: I Thorac Surg. 2018; Full Text Full Text PDF PubMed Scopus Google Scholar of these has and In an to the root and prevent autograft several have using the aortic root to support to the pulmonary autograft The largest of this technique from the who reported their experience with this in patients age, P.D. Mokhles M.M. Takkenberg J.J. Larobina M. O'Keefe M. Wynne R. et al.The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.J Thorac Cardiovasc Surg. 2015; 149: S46-S52Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar The long-term results were with root to 15 years after Indeed, only of patients had a aortic root size at follow-up, and none had an aortic root size with patients who presented with preoperative AR and a dilated aortic annulus were at higher risk of increased root and reoperation at freedom from reoperation was at 15 years, and none of the were by autograft In a of this cohort on patients age, ± who presented with and AR, and P.D. Mokhles M.M. Takkenberg J.J. Larobina M. O'Keefe M. Wynne R. et al.The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.J Thorac Cardiovasc Surg. 2015; 149: S46-S52Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar reported a of for AR, 2 for freedom from reoperation of at 20 In this most autograft early the years after was also a large with of in the of patients, before of the surgical The results with the autologous inclusion technique represent the best long-term outcomes of the Ross procedure in patients with AR, that when this is an excellent to the root. The main of this is that it is not for patients with unicuspid or bicuspid when is a large size between the aortic and pulmonary roots. prevent autograft several have the pulmonary autograft within a Dacron before implantation T. A. clinical and after pulmonary autograft Ross Thorac Cardiovasc 2016; Full Text Full Text PDF PubMed Scopus Google T. M. F. T. 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A. results following of the pulmonary autograft to prevent dilatation after the Ross procedure.J Thorac Cardiovasc Surg. 2008; Full Text Full Text PDF PubMed Scopus (38) Google Scholar, F. C. A. T. C. et Ross operation with of the pulmonary autograft: results.J Thorac Cardiovasc Surg. 2010; Full Text Full Text PDF PubMed Scopus Google Scholar, F. M. C. Ross operation to prevent pulmonary autograft J Cardiothorac Surg. PubMed Scopus Google Scholar, I. Ross procedure to prevent autograft Thorac Surg. 2010; (discussion Full Text Full Text PDF PubMed Scopus Google Scholar, C.L. E. Larobina M. Wynne R. O'Keefe M. J. et al.The Ross procedure in adults presenting with bicuspid aortic valve and aortic freedom from reoperation at 20 J Cardiothorac Surg. 2018; PubMed Scopus Google Scholar The main of this is that it the of the autograft root and impairs its some of the main of the Ross Furthermore, studies have shown that the of to and which