Spectrum and outcome of reoperations after the ross procedure

Background: Proposed advantages to the Ross procedure included presumed increased freedom from reoperation and simpler reoperation for pulmonary conduit replacement if needed. It is increasingly apparent, however, that reoperations are frequent after the Ross procedure and that when required, they may be more complex than previously thought. Methods and Results: Between September 1991 and August 2008, 56 patients underwent reoperation at our institution after a Ross procedure performed by ourselves (n=13) or elsewhere (n=43). Median age at first reoperation at our institution was 26 years (range 1 to 69 years). The 4 most common indications for reoperation were isolated autograft (neoaortic) regurgitation in 11 cases (20%), isolated pulmonary conduit regurgitation/ stenosis in 9 (16%), combined autograft regurgitation/dilatation in 8 (14%), and combined autograft regurgitation and pulmonary conduit regurgitation/stenosis in 6 (11%). A total of 144 procedures were performed in these 56 patients during first reoperation at our institution. The autograft valve required replacement in 21 cases (38%) and aortic root replacement in 21 (38%), with ascending aortic/arch reconstruction in 13 (23%) and mitral valve surgery in 5 (9%). The pulmonary valve was replaced in 33 cases (59%) and the tricuspid valve was repaired/replaced in 10 (18%). Early mortality was 1.8% (1 of 56 patients), and morbidity included 6 patients with respiratory failure and 3 who required postcardiotomy extracorporeal membrane oxygenation. There were 4 late deaths during the median follow-up of 8 months (range 1 to 179 months). Conclusions: A broad spectrum of complex reoperations may be required after the Ross procedure. Patients and family members considering the procedure should be informed of the potential for associated morbidity should reoperation be necessary.