A critical reappraisal of the Ross operation - Renaissance of the subcoronary implantation technique?

Background - The autograft procedure, an option in aortic valve replacement, has undergone technical evolution. A considerable debate about the most favorable surgical technique in the Ross operation is still ongoing. Originally described as a subcoronary implant, the full root replacement technique is now the most commonly used technique to perform the Ross principle. Methods and Results - Between June of 1994 and June of 2005, the original subcoronary autograft technique was performed in 347 patients. Preoperative, perioperative, and follow- up data were collected and analyzed. Mean patient age at implantation was 44 +/- 13 years (range 14 to 71 years; 273 male, 74 female). Bicuspid valve morphology was present in 67%. The underlying valve disease was aortic regurgitation in 111 patients, stenosis in 46 patients, combined lesion in 188 patients, and active endocarditis in 22 patients (in 2 patients without stenosis or regurgitation). Concomitant procedures were performed in 130 patients. Clinical and echocardiographic follow- up visits were obtained annually (mean follow up 3.9 +/- 2.7 years, 1324 patient-years; completeness of follow-up 99.4%). The in- hospital mortality rate was 0.6% (n = 2), and the late mortality was 1.7% ( n = 6), with 5 noncardiac deaths (4 cancer, 1 multiorgan failure after noncardiac surgery) and 1 cardiac death (sudden death). At last follow- up, 94% of the surviving patients were in New York Heart Association class I. Ross procedure-related valvular reoperations were necessary in 9 patients: Three received autograft explants, 5 received homograft explants, and 1 received a combined auto- and homograft explant. At last follow-up visit, autograft/ homograft regurgitation grade II was present in 5/ 10 patients and grade III in 4/ 0. Maximum/mean pressure gradients were 7.4 +/- 6.2/3.7 +/- 2.1 mm Hg across the autograft and 15.3 +/- 9.4/7.6 +/- 5.0 mm Hg across the right ventricular outflow tract, respectively. Aortic root dilatation was not observed. Freedom from any valve-related intervention was 95% at 8 years (95% confidence interval 91% to 99%). Conclusion - Midterm follow-up of autograft procedures according to the original Ross subcoronary approach proves excellent clinical and hemodynamic results, with no considerable reoperation rates. Revival of the original subcoronary Ross operation should be taken into account when considering the best way to install the Ross principle.