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(Circulation. 2007;116:I-251 – I-258.)
© 2007 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Autograft Regurgitation and Aortic Root Dimensions After the Ross Procedure

The German Ross Registry Experience

Thorsten Hanke, MD; Ulrich Stierle, MD; Juergen O. Boehm, MD; Cornelius A. Botha, MD; J.F. Matthias Bechtel, MD; Armin Erasmi, MD; Martin Misfeld, MD, PhD; Wolfgang Hemmer, MD; Joachim G. Rein, MD; Derek R. Robinson, MA, MSc DPhil CStat; Rüdiger Lange, MD; Jürgen Hörer, MD; Anton Moritz, MD; Feyzan Özaslan, MD; Thorsten Wahlers, MD, PhD; Ulrich F.W. Franke, MD; Roland Hetzer, MD, PhD; Michael Hübler, MD; Gerhard Ziemer, MD; Bernhard Graf, MD; Donald N. Ross, MD; Hans H. Sievers, MD, on behalf of the German Ross Registry

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

Correspondence to Prof Dr Hans H. Sievers, University Schleswig-Holstein, Campus Luebeck, Department of Cardiac Surgery, Ratzeburger Allee 160, 23538 Luebeck, Germany. E-mail sievers{at}herzchirurgie.uni-luebeck.de

Background— Autograft regurgitation and root dilatation after the Ross procedure is of major concern. We reviewed data from the German Ross Registry to document the development of autograft regurgitation and root dilatation with time and also to compare 2 different techniques of autograft implantation.

Methods and Results— Between 1990 and 2006 1014 patients (786 men, 228 women; mean age 41.2±15.3 years) underwent the Ross procedure using 2 different implantation techniques (subcoronary, n =521; root replacement, n =493). Clinical and serial echocardiographic follow up was performed preoperatively and thereafter annually (mean follow up 4.41±3.11 years, median 3.93 years, range 0 to 16.04 years; 5012 patient-years). For statistical analysis of serial echocardiograms, a hierarchical multilevel modeling technique was applied. Eight early and 28 late deaths were observed. Pulmonary autograft reoperations were required in 35 patients. Initial autograft regurgitation grade was 0.49 (root replacement 0.73, subcoronary 0.38) with an annual increase of grade 0.034 (root replacement 0.0259, subcoronary 0.0231). Annulus and sinus dimensions did not exhibit an essential increase over time in both techniques, whereas sinotubular junction diameter increased essentially by 0.5 mm per year in patients with root replacement. Patients with the subcoronary implantation technique showed nearly unchanged dimensions. Bicuspid aortic valve morphology did not have any consistent impact on root dimensions with time irrespective of the performed surgical technique.

Conclusions— The present Ross series from the German Ross Registry showed favorable clinical and hemodynamic results. Development of autograft regurgitation for both techniques was small and the annual progression thereof is currently not substantial. Use of the subcoronary technique and aortic root interventions with stabilizing measures in root replacement patients seem to prevent autograft regurgitation and dilatation of the aortic root within the timeframe studied.

Key Words: aortic regurgitation • aortic root dimensions • implantation technique • Ross procedure