The pulmonary autograft after the Ross operation: Results of 25 year follow-up in a pediatric cohort.

Abstract Background Progressive autograft dilation and need for later reoperation remain major concerns of the Ross procedure. The study investigates the clinical outcome after the Ross operation, including a longitudinal analysis of autograft dimensions over 25 years. Methods From November 1991 to April 2019, 137 patients underwent a Ross procedure at the University Hospitals of UCL-Brussels and Ghent. Inclusion criteria were age≤18 years and pulmonary autograft implantation by root replacement. Outcome focused on survival, reoperation rate and autograft size evolution through linear mixed model analysis. Results A Ross or Ross-Konno operation was performed in 110(80%) and 27(20%)patients at a median age of 10.4y(4.7-14.3) and 0.5y(0.04-5.2). Overall 10 and 20 year survival was 87±3% and 85±3%, but 93±3% for isolated Ross patients. RVOT-conduit exchange was required in 20.3%, whereas autograft-related reoperation was performed in 14(10.7%) patients at a median interval of 14y(9-16), respectively for aortic regurgitation(n=2) and autograft dilation(n=12). Autograft z-values increased significantly at the sinus and sinotubular junction(STJ) compared to the annulus(Annulus:0.05±0.38/y - Sinus:0.14±0.25/y – STJ:0.17±0.34/y, p=0.015). The z-value slope for autograft dimensions was significantly steeper for Ross-Konno versus Ross patients(Annulus:p=0.029 – Sinus:p Conclusions The Ross operation offers children requiring aortic valve replacement(AVR) an excellent survival perspective, with an acceptable risk of autograft reoperation within the first 25 years. Contrary to the autograft annulus, dilation of the sinus and STJ size is of concern. Closer surveillance of autograft dimensions might be required in patients who underwent a Ross-Konno procedure and/or aortic arch reconstruction.