Fate of the remaining neo-aortic root after autograft valve replacement with a stented prosthesis for the failing ross procedure

Background: Aortic root replacement (ARR) is advocated for irreparable autograft failure after the Ross procedure to avoid late aneurysm formation. However, redo ARR is complex and associated with bleeding and coronary injury risks. We examine results of autograft valve replacement (AuVR) with stented prostheses (SP) without ARR with special focus on the fate of the remaining root and need for reintervention. Methods: Between 1994 and 2011, 50 of 510 Ross patients underwent AuVR with SP. Serial postoperative echocardiograms (n = 342) were analyzed and regression models adjusted for repeated measures were used to model longitudinal change of the remaining root and ascending aorta dimensions after AuVR. Results: Fifty patients, median age 21 years (range 11 to 50 years) underwent AuVR with SP: mechanical (n = 38) or tissue (n = 12). Thirty patients (60%) had concomitant procedures; most commonly mitral valve surgery (n = 20) or conduit change (n = 12). There were no operative deaths and 10-year survival was 95%. Freedom from prosthesis, root, and all-cause reoperations was 97%, 98%, and 90% at 10 years, respectively. Serial echocardiography data showed that there was little but, nevertheless, progressive increase of the remaining root (EST: +0.0190 [0.0041] cm/year, p < 0.001) and ascending aorta diameters (EST: +0.0191 [0.0037] cm/year, p < 0.001). While there was small steady non-statistically significant increase in mean prosthesis gradient (estimate [EST]: +0.16 [0.09] mm Hg/year, p = 0.08); ejection fraction remained stable with time (EST: -0.12 [0.14] %/year, p = 0.41). Conclusions: Our results indicate that AuVR with SP without ARR for failing autografts is justified as it is associated with low mortality and reoperation risk. Preemptive complex ARR should be reserved for those with significant root dilatation at time of AuVR. Although root reinterventions are rare, patients should be followed for progressive root dilatation. Faster growth is seen in those who fail with regurgitation and dilated annulus.