The Ross–Yacoub procedure for aneurysmal autograft roots: A strategy to preserve autologous pulmonary valves

Objectives

Autograft dilatation is leading to an increase in root reoperations late after the Ross procedure. A 14-year clinical experience was reviewed to define the feasibility and outcome of the autograft valve–sparing root reoperation.

Methods

One hundred twenty-six patients surviving an average of 7.4 ± 9.9 years after the Ross procedure underwent cross-sectional clinical and echocardiographic examination. Study end points were freedom from autograft dilatation (diameter >4 cm or 2.1 cm/m²), root reoperation, root replacement, and functional outcome after the valve-sparing reoperation.

Results

Thirty-one (25%) patients had dilatation, with 45% ± 9% freedom at 14 years. In 14 (11%) patients an autograft aneurysm (>5.0 cm) was found: 12 had reoperations at 8.9 ± 2.6 years after the Ross procedure. Risk factors for root reoperation at multivariate analysis were root technique (P = .01), root dilatation (P = .001), and follow-up duration (P = .06). Two patients had root replacement, and 10 (83%) had remodeling with valve preservation (8 Yacoub procedures and 2 sinotubular junction/ascending aorta procedures); all survived reoperation. Absence of severe autograft insufficiency (P = .04) and convergent-type aneurysm (P = .05) were associated with successful valve preservation. Fourteen-year freedom from root reoperation was 80% ± 7%, and freedom from full root replacement was 97% ± 4%. At 3.2 ± 1.5 years (range, 0.2–4.8 years) after root reoperation, all patients are in New York Heart Association class I and are medication free: 9 of 10 patients have mild autograft valve insufficiency or less, and 1 required valve replacement 51 months after remodeling. One patient carried out 2 uncomplicated pregnancies 3 and 4 years after the Ross–Yacoub procedure.

Conclusions

Root reoperation with pulmonary valve preservation is feasible in the majority of patients with autograft aneurysms, allowing for maintenance of normal quality of life. Referral of patients with a dilated root before the appearance of severe valve insufficiency increases the likelihood of pulmonary valve sparing. Functional behavior of remodeled autograft roots is rewarding; however, continued observation is warranted.

CTSNet classification: 20, 26, 35