Re-interventions on the autograft and the homograft after the Ross operation in children

Background: For children who require aortic valve replacement, the pulmonary autograft may be the ideal substitute. However, re-operations for conduit exchange in the pulmonary position are inevitable. In addition, re-operations on the autograft may be necessary due to dilatation and neo-aortic insufficiency. We sought to assess predictors for re-intervention in an international Ross-operated paediatric population.

Methods: Data of 152 children below 16 years of age at the time of the Ross operation were analysed using Cox proportional hazard modelling. Mean follow-up time was 6.1+/-4.2 years.

Results: The median age at the time of the Ross operation was 10.1 years (range 54 days to 15 years). Early mortality was 2.6%. Survival at 5 and 10 years was 93.9+/-2.0% and 90.4+/-3.1%, respectively. Seven patients required autograft re-intervention (explantation n=6 and reconstruction n=1). Freedom from autograft re-intervention at 5 and 10 years was 99.3+/-0.7% and 95.5+/-2.7%, respectively. Prior endocarditis (p=0.061), prior aortic regurgitation (p=0.061) and longer follow-up time (p=0.036) emerged as risk factors for autograft re-intervention. Seventeen patients required 36 conduit re-interventions (replacement n=16, percutaneous valvuloplasty n=10). Freedom from conduit re-intervention at 5 and 10 years was 89.3+/-2.9% and 79.6+/-6.1%, respectively. Implantation of an aortic homograft (p=0.013), and smaller conduit size (p=0.074) emerged as risk factors for conduit re-intervention.

Conclusions: There is a consistent need for conduit re-intervention following the Ross operation in children. Re-interventions on the autograft are rare within the first decade after surgery. However, the number of autograft re-interventions may increase after the first decade, since longer follow-up time is a risk factor for autograft failure.