The Ross procedure in children and young adults: a word of caution.

BACKGROUND

Disease of the aortic valve in children and young adults is a complex entity whose management is the subject of controversy. The Ross and the Ross-Konno procedures have become the primary choices for aortic valve replacement in children because of growth potential, optimal hemodynamic performance, and lack of the need for anticoagulation. However, concern persists regarding the longevity of the pulmonary autograft, especially in patients with aortic insufficiency.

METHODS

Between June 1993 and February 2000, 72 Ross and Ross-Konno procedures were performed at our institution: 81% of the patients were less than 15 years old. Preoperative, postoperative, and follow-up clinical, echocardiographic, and hemodynamic data were reviewed. Statistical analysis was performed to identify the risk factors for deteriorating autograft function.

RESULTS

Aortic insufficiency was an indication for the Ross procedure in 17 patients and mixed lesions with predominant aortic insufficiency in 10. Of the 45 other patients, 32 had aortic stenosis and 13 had mixed lesions with predominant aortic stenosis. There were no deaths during a follow-up of 5 to 80 months. Autograft reoperation was necessary in the follow-up period in 7 patients for severe aortic insufficiency. Moderate insufficiency was identified in 5 additional patients. Aortic insufficiency or predominant aortic insufficiency, as a preoperative hemodynamic indication for the Ross procedure, reached statistical significance (P =.031) as a risk factor for autograft failure.

CONCLUSION

The Ross and the Ross-Konno procedures have changed the prognosis of children and young adults with complex aortic valve disease. However, the Ross procedure should be performed with caution in older children in whom aortic insufficiency is a preoperative hemodynamic indication. Further follow-up to delineate the risk factors for autograft dysfunction in children and young adults is necessary to better define the indications for the Ross procedure.