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Ross Procedure Inappropriate for Younger Patients with Rheumatic Heart Disease

Implantation of a pulmonary autograft (the Ross procedure) is now well accepted as a therapeutic option for aortic valve replacement. Benefits include the autograft's potential for growth, excellent flow characteristics, and freedom from prosthetic-valve complications or anticoagulation. In this retrospective study from India, investigators analyzed outcomes for 102 consecutive patients (mean age, 28 years) with aortic valve lesions (73 percent from rheumatic disease; 26 percent from congenital bicuspid aortic valve disease) who underwent the Ross procedure between October 1993 and March 1998. Of the 102 patients, 31 underwent additional associated surgical procedures. All patients younger than 45 with rheumatic heart disease received penicillin prophylaxis after surgery.

Operative and late mortality rates were 6.9 percent and 7.8 percent, respectively. Thirteen patients with rheumatic disease developed moderate (3+) to severe (4+) aortic regurgitation 8 to 48 months after initial surgery. Two patients had recurrent rheumatic fever, and two required reoperation. Pathologic examination of explanted autografts revealed features compatible with rheumatic valvulitis. The probability of normal autograft function after five years was lower for those with rheumatic aortic valve disease than for those with nonrheumatic disease (60 percent vs. 100 percent, respectively). Younger age (less than 30 years) and associated mitral valve disease were independent predictors of autograft failure.

Comment: The Ross procedure is inappropriate for most young adults with rheumatic heart disease because of the increased risk for recurrent valvulitis and early graft failure. Other studies have described progressive dilatation of the autograft in patients with congenital aortic valve disease. The pulmonary autograft appears to be most suitable for middle-aged adults who wish to avoid anticoagulation following aortic valve replacement.

— GW Dec

Published in Journal Watch Cardiology October 14, 1999

Citation(s):

Choudhary SK et al. Pulmonary autograft: Should it be used in young patients with rheumatic disease?. J Thorac Cardiovasc Surg 1999 Sep 118 483-491.

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