Division of Cardiac Surgery and Radiology, University of Verona, Verona, Italy.
Eur J Cardiothorac Surg. 2012 Jun;41(6):1309-14; discussion 1314-5. doi: 10.1093/ejcts/ezr243. Epub 2012 Jan 16.
Autograft valve and root pathology is the leading cause of Ross procedure failure. To define risk and outcome of autograft valve/root repair at reoperation, a 17-year experience was analysed.
One hundred and thirty-two consecutive late survivors underwent cross-sectional clinical and echocardiographic examination on average 10.8 ± 14.7 years (range 0.4-17) after Ross procedure. Study endpoints were hospital and late morbidity, freedom from autograft reoperation, freedom from root/valve replacement and functional outcome after valve/root repair.
Twenty-seven (20%) patients underwent 33 cardiac reoperations, the first on average 7.7 ± 4.5 years (range 0.08-16.2) after Ross operation. Nineteen had undergone root replacement, 5 inclusion cylinder and 3 subcoronary grafting. Indication was root pathology in 17 (63%) patients and isolated valve in 10. Surgery consisted in valve repair/sparing in 17 patients and valve/root replacement in 10, with no hospital mortality. Freedom from any autograft valve/root reoperation was 74 ± 5% at 15 years. No patient with valve/root replacement required second reoperation. Instead, 6/17 (35%) patients having autograft valve repair/sparing and followed for 4.2 ± 2.9 years (range 0.3-10.8) required re-repair/AVR, while 11 present mild AI or less. Freedom from autograft valve/root replacement was 83 ± 5% at 15 years. At multivariate analysis, predictors of reoperation were age at Ross (P = 0.002) and use of root technique (P = 0.049). Failure of autograft valve repair/sparing was associated with isolated valve pathology (P = 0.014) and earlier reoperation (P = 0.002). Pre-repair autograft insufficiency was significant at univariate analysis only (P = 0.01).
Autograft reoperation carries negligible hospital risk. Pulmonary valve sparing or repair is feasible in half of patients with Ross failure. Concomitant root remodelling and absence of preoperative severe valve dysfunction predict successful and durable repair.
自体移植物瓣膜和根部病变是 Ross 手术失败的主要原因。为了明确再次手术时自体移植物瓣膜/根部修复的风险和结果，对 17 年的经验进行了分析。
132 例晚期存活的连续患者在 Ross 手术后平均 10.8 ± 14.7 年（范围 0.4-17）进行了横断面临床和超声心动图检查。研究终点为住院和晚期发病率、自体移植物免于再次手术、免于根部/瓣膜置换以及瓣膜/根部修复后的功能结果。
27 例（20%）患者进行了 33 次心脏再次手术，首次手术平均在 Ross 手术后 7.7 ± 4.5 年（范围 0.08-16.2）。19 例行根部置换，5 例行包绕圆柱，3 例行冠下单根移植。17 例（63%）患者的适应证为根部病变，10 例为单纯瓣膜病变。手术方式为瓣膜修复/保留 17 例，瓣膜/根部置换 10 例，无住院死亡。15 年时，任何自体移植物瓣膜/根部再次手术的无事件率为 74 ± 5%。无瓣膜/根部置换患者需要再次手术。相反，17 例行自体移植物瓣膜修复/保留的患者中有 6 例（35%）随访 4.2 ± 2.9 年（范围 0.3-10.8）需要再次修复/AVR，而 11 例患者仅存在轻度 AI 或更少。15 年时，自体移植物瓣膜/根部置换的无事件率为 83 ± 5%。多变量分析显示，Ross 手术时的年龄（P = 0.002）和根部技术的使用（P = 0.049）是再次手术的预测因素。自体移植物瓣膜修复/保留失败与单纯瓣膜病变（P = 0.014）和较早的再次手术（P = 0.002）有关。修复前自体移植物功能不全仅在单变量分析中有意义（P = 0.01）。
自体移植物再次手术的住院风险可忽略不计。Ross 手术失败的患者中有一半可行肺动脉瓣保留或修复。同时进行根部重塑且术前无严重瓣膜功能障碍可预测成功且持久的修复。
