Author + information
- Paul Stelzer, MD∗ ( and )
- Robin Varghese, MD, MS
- ↵∗Address for correspondence:
Dr. Paul Stelzer, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, 1190 Fifth Avenue, Box 1028, New York, New York 10029.
Martin et al. (1) are to be congratulated for the 100% follow-up of a large series of patients up to 25 years after a Ross procedure, published in this issue of the Journal. They demonstrated excellent initial success with dedicated surgical expertise at work, resulting in only 4 deaths (1.3% 30-day mortality), all of which were in the first 10 years of the program. This is similar to our own “learning curve,” presented several years ago, which now has 624 patients with only 6 early deaths and none in the past 415 cases (2).
The investigators’ primary hypothesis was that patients who have undergone such complex surgery involving both aortic and pulmonary root replacement could not possibly have a normal life expectancy. Despite this hypothesis, at least 3 other studies have shown normal life expectancy for 15 to 20 years after a Ross procedure (3). With such robust follow-up, this study demonstrates that survival is not normal at 20 years, but it is not very far below the age-matched population. The extremely high significance of the p value is misleading, because there were only 28 late deaths in this long series, and Ross-related reoperations accounted for only 3 of those, while coronary disease claimed 8, suicide 3, and malignancy 5. Slightly fewer non-Ross-related deaths would have left the statistics failing to prove the hypothesis at 20 years and waiting for 30.
Notably, 77.3% of patients younger than 55 years had alternative valves, primarily mechanical or animal tissue devices. Unfortunately, the investigators do not include the follow-up of those patients, which would be valuable future research. The discussion points out the limitations of the mechanical and tissue valve alternatives in young people; however, the very sobering curves from Anselmi et al. (4) and Ruel et al. (5) were not on the graph of comparative survival. Whereas the overall survival in the presented Ross group was 83.6% at 20 years, the survival was only 80.1% at 15 years with tissue valves, 52% with mechanical valves in Canada, and only 65% at 15 years with bovine pericardial valves in France. Furthermore, freedom from bioprosthetic structural valve deterioration at 15 years was only 48.7%. These are the numbers that really matter to the patients who need aortic valve replacement and the doctors who advise them. One may still argue that the Ross procedure does not put them back on the normal life expectancy curve, but nothing else comes nearly as close.
Predicting Ross Failure
Martin et al. (1) point out that specific risk factors (aortic regurgitation with a dilated annulus and ascending aortic replacement) increase the incidence of long-term failure of the Ross procedure. These cases of dilated aortic annulus or ascending aortic aneurysm provide opportunities to improve the surgical technique rather than deprive patients with these risk factors from getting the benefits of the Ross procedure. When possible, pure aortic regurgitation should be managed with a valve-sparing aortic root reconstruction. If not feasible, the Ross procedure is an option that can be used but must be externally supported to prevent late dilation with subsequent aortic regurgitation.
Martin et al. (1) suggest that the decreased elasticity of an ascending aortic vascular graft puts more stress on the autograft root, which increases the chances of failure. It may well be that the demonstrated presence of bicuspid aortopathy results in a similar process in the pulmonary artery wall as outlined in histopathologic studies by de Sa et al. (6).
Either way, external support of the autograft root with prosthetic patches or enclosing the entire root in a vascular graft is a safe technique (7). The fact that this series routinely did not support the annulus or the sinotubular junction is probably why the investigators found this to be a risk factor for late failure. The prolific group in Stuttgart, Germany, reported a series of 645 consecutive Ross patients, using routine reinforcement techniques, including 209 (32.4%) with replacement and 59 (9.1%) with remodeling of the ascending aorta and found no increase in failure rate.
The pulmonary homograft has been the subject of controversy all along as part of turning a single valve into a 2-valve operation with 2 valves being left at risk for the long term. The pulmonary homograft has proved superior for this purpose. Martin et al. (1) used a very strict definition of homograft failure that overemphasized the clinical effect of moderate pulmonary regurgitation. Treating congenital lesions such as tetralogy and pulmonary stenosis often leaves severe pulmonary regurgitation, which is well tolerated for years as long as the pulmonary artery pressure is low. Conversely, 11 of 18 patients with stenosis required replacement. At 20 years, freedom from homograft intervention was excellent at 83% and consistent with most other series. In the current age of decellularzied homografts, one may expect this to improve further.
It has been our experience and that of others that larger homografts are the best way to prevent stenosis (8). This is just the opposite of the investigators’ conclusion that larger homografts increase the rate of failure, even though it does not happen until after 10 years. Interestingly, the mean size used was only 25 mm, which is well below our standard of 29 to 32 mm, which allows for the initial 2 years of “shrinkage” reported by some and has a dramatic impact on the incidence of stenosis in the first decade. Contrary to most published series, this group reports that regurgitation, not stenosis, was the primary mode of homograft failure and that larger homograft sizes were more likely to fail. We wonder if choosing a smaller homograft size led to stretching of the homograft annulus and subsequent regurgitation. Their finding that a larger homograft size predicts failure directly contradicts the findings of most other series and requires further investigation.
Also important in the discussion is the advent and further potential for transcatheter technologies to extend the life of the Ross operation. This would avoid redo sternotomy, making it both more attractive to do a Ross procedure in the first place and more important to make sure the neoaortic root is supported.
Although freedom from reintervention and mortality are important outcomes to consider, we must also consider quality of life when offering treatment options to patients. The evidence suggests that the Ross procedure provides young active patients with a better quality of life compared with valve replacement, and this finding should weigh heavily when considering options for young patients with aortic valve disease (2).
Finally, Martin et al. (1) conclude that “it appears that the Ross procedure confers a solid survival advantage over commonly used valve substitutes.” It is our hope that readers will not miss this message. A young patient with aortic valve disease is not looking for immortality; he or she is looking for the longest life with the best quality possible. This study, along with numerous preceding studies, provides robust support that the Ross procedure should be the operation of choice for patients <50 years of age, with unrepairable aortic valve disease.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
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