The Ross-Yacoub procedure for aneurysmal autograft roots: a strategy to preserve autologous pulmonary valves

Abstract

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/m(2)), 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.