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Ross Procedure in Neonates and Infants: a European Multicenter Experience
Aart Mookhoek, MD1, Efstratios I. Charitos, MD2, Mark G. Hazekamp, MD, PhD3, Ad J J C Bogers, MD, PhD1, Jürgen Hörer, MD4, Roland Hetzer, MD, PhD5, Joerg S. Sachweh, MD6, Arlindo Riso, MD6, Ulrich Stierle, MD2, Johanna J M Takkenberg, MD, PhD1, Paul H. Schoof, MD, PhD7.
1Erasmus University Medical Center, Rotterdam, Netherlands, 2University of Lübeck, Lübeck, Germany, 3Leiden University Medical Center, Leiden, Netherlands, 4German Heart Center Munich, Munich, Germany, 5German Heart Center Berlin, Berlin, Germany, 6University Heart Center Hamburg, Hamburg, Germany, 7University Medical Center Utrecht, Utrecht, Netherlands.

OBJECTIVE: Infants and neonates with severe left ventricular outflow tract obstruction may require replacement of the aortic root when more conservative treatment modalities are unsuccessful. In this retrospective multicenter cohort study, we present our experience with pulmonary autograft replacement of the aortic root in neonates and infants with a focus on late survival and freedom from graft reintervention. METHODS: A total of 76 infants (age < 1 year) from 6 centers in The Netherlands and Germany underwent the Ross procedure between 1990 and 2013. RESULTS: Patients received the Ross (32%) or Ross-Konno procedure (68%) with a full, unsupported root. Median age at operation was 85 days (range 6 - 347 days). Hospital mortality (N=13, 17%) was associated with neonatal age, pre-operative inotropic medication and circulatory arrest strategy at operation. Five patients (9%) died during follow-up: 3 patients died of heart failure, 1 following balloon dilatation of a stenotic right ventricular outflow tract graft and 1 of unknown causes. Cumulative survival at 8 years was 75% (95% CI = 63% - 84%) (Figure 1). Only one patient required autograft reintervention after 75 days for aortic regurgitation due to a torn leaflet. At last follow-up, no patients presented with more than moderate (grade ≥ 3) autograft regurgitation. Freedom from right ventricular outflow tract reintervention was 58% (95% CI = 40% - 72%) at 8 years, with superior results in pulmonary homografts compared to aortic homografts or xenografts. CONCLUSIONS: The Ross procedure is an adequate surgical treatment for infants and neonates with critical aortic valve stenosis. At last follow-up, no signs of late autograft failure were observed. Late mortality was associated with chronic heart failure, which may be related to intrinsic abnormalities of the left ventricle or peri-operative ischemic damage.

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