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(Circulation. 2009;120:S146-S154.)
© 2009 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Autograft Reinforcement to Preserve Autograft Function After the Ross Procedure

A Report From the German-Dutch Ross Registry

Efstratios I. Charitos, MD; Thorsten Hanke, MD; Ulrich Stierle, MD; Derek R. Robinson, MA, MSc, DPhil, CStat; Ad J.J.C. Bogers, MD; Wolfgang Hemmer, MD; Matthias Bechtel, MD; Martin Misfeld, MD, PhD; Armin Gorski, MD; Juergen O. Boehm, MD; Joachim G. Rein, MD; Cornelius A. Botha, MD; Ruediger Lange, MD; Juergen Hoerer, MD; Anton Moritz, MD; Thorsten Wahlers, MD, PhD; Ulrich F.W. Franke, MD; Martin Breuer, MD; Katharina Ferrari-Kuehne, MD; Roland Hetzer, MD, PhD; Michael Huebler, MD; Gerhard Ziemer, MD; Johanna J.M. Takkenberg, MD, PhD; Hans H. Sievers, MD, on behalf of the German-Dutch Ross Registry

From the Department of Cardiac and Thoracic Vascular Surgery (E.I.C., T.H., U.S., M.B., M.M., A.G., H.H.S.), University of Luebeck, Germany (Registry Site); the Department of Mathematics, School of Science and Technology (D.R.R.), University of Sussex, Brighton, UK; Erasmus Medical Center (A.J.J.C.B., J.J.M.T.), Rotterdam, The Netherlands; Sana Herzchirurgische Klinik (W.H., J.O.B., J.G.R.), Stuttgart, Germany; Herzzentrum Bodensee (C.A.B.), Konstanz, Germany; the German Heart Center (J.H.), Munich, Germany; Johann-Wolfgang-Goethe-University (A.M.), Frankfurt/Main, Germany; University of Cologne (T.W.), Germany; Robert-Bosch-Hospital (U.F.W.F.), Stuttgart, Germany; Friedrich-Schiller-University (M.B., K.F.-K.), Jena, Germany; the German Heart Center (R.H., M.H.), Berlin, Germany; and Eberhard-Karls-University (G.Z.), Tuebingen, Germany.

Correspondence to Hans-H. Sievers, MD, University of Luebeck, Department of Cardiac and Thoracic Vascular Surgery, Ratzeburger Allee 160, 23538 Luebeck, Germany. E-mail sievers{at}medinf.mu-luebeck.de

Background— Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve autograft function and improve durability. The aim of this study is to evaluate this hypothesis.

Methods and Results— 1335 adult patients (mean age:43.5±12.0 years) underwent a Ross procedure (subcoronary, SC, n=637; root replacement, Root, n=698). 592 patients received R of the annulus, sinotubular junction, or both. Regular clinical and echocardiographic follow-up was performed (mean:6.09±3.97, range:0.01 to 19.2 years). Longitudinal assessment of autograft function with time was performed using multilevel modeling techniques. The Root without R (Root–R) group was associated with a 6x increased reoperation rate compared to Root with R (Root+R), SC with R (SC+R), and without R (SC-R; 12.9% versus 2.3% versus 2.5%.versus 2.6%, respectively; P<0.001). SC and Root groups had similar rate of aortic regurgitation (AR) development over time. Root+R patients had no progression of AR, whereas Root–R had 6 times higher AR development compared to Root+R. In SC, R had no remarkable effect on the annual AR progression. The SC technique was associated with lower rates of autograft dilatation at all levels of the aortic root compared to the Root techniques. R did not influence autograft dilatation rates in the Root group.

Conclusions— For the time period of the study surgical autograft stabilization techniques preserve autograft function and result in significantly lower reoperation rates. The nonreinforced Root was associated with significant adverse outcome. Therefore, surgical stabilization of the autograft is advisable to preserve long-term autograft function, especially in the Root Ross procedure.

Key Words: valves • autograft • echocardiography • surgery • registry