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Valve-sparing Reoperations after Ross Procedure: a European Multicenter Experience
Aart Mookhoek, MD1, Laurent de Kerchove, MD2, Gebrine El Khoury, MD2, Timo Weimar, MD3, Giovanni Battista Luciani, MD4, Alessandro Mazzucco, MD4, Ad J J C Bogers, MD, PhD1, Diana Aicher, MD5, Hans-Joachim Schäfers, MD, PhD5, Efstratios I. Charitos, MD6, Ulrich Stierle, MD6, Johanna J M Takkenberg, MD, PhD1.
1Erasmus University Medical Center, Rotterdam, Netherlands, 2Cliniques Universitaires Saint-Luc, Brussels, Belgium, 3Sana Cardiac Surgery Stuttgart, Stuttgart, Germany, 4University of Verona, Verona, Italy, 5Saarland University Medical Center, Homburg, Germany, 6University of Lübeck, Lübeck, Germany.

OBJECTIVE: Autograft leaflet preservation at reoperation conserves the advantages of the Ross procedure, which include good hemodynamics and freedom from oral anticoagulation. However, repair is expected to result in lower durability compared to implantation of a mechanical valve prosthesis. In this retrospective multicenter cohort study, we present our experience with valve-sparing reoperations with a focus on long-term repair durability. METHODS: A total of 85 patients from 6 centers in Europe underwent a valve-sparing reoperation following the Ross procedure between 1997 and 2013. RESULTS: Valve-sparing repair was performed a median of 9.1 years (interquartile range 5.8-12.5 years, range 6 days to 20.7 years) after the Ross procedure. The initial Ross procedure, performed at a median age of 30.4 years (interquartile range 16.0-42.5 years), was mostly performed with the full root technique (85%). At the time of valve-sparing reoperation, severe aortic regurgitation (grade ≥ 3) and cusp prolapse were present in 44% and 40% of patients, respectively. The reoperation included cusp repair in 44% of patients. In-hospital mortality was 1%. During a median follow-up of 4.3 years, 3 more patients died of non-cardiac causes resulting in a cumulative survival at 8 years of 89% (95% CI: 65%-97%). Freedom from repaired autograft reintervention at 8 years was 76% (95% CI: 57%-87%) with 15 patients requiring reintervention, mainly in the first 2 post-operative years (Figure). Potential risk factors for autograft repair failure included isolated autograft regurgitation without root dilatation, younger patient age at the time of repair and absence of autograft root replacement (isolated repair of autograft leaflets). In patients with a successful autograft repair, severe aortic regurgitation (grade ≥ 3) was present in only 3% at last follow-up. CONCLUSIONS: Valve-sparing autograft reoperations carry a low operative risk, and in the majority of patients a durable result is achieved in the first postoperative decade. Repair durability in patients with isolated severe pulmonary autograft regurgitation is suboptimal, and requires careful preoperative weighing of surgical repair and replacement options.

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