CAN PULMONARY AUTOGRAFT DILATATION BE PREVENTED IN PATIENTS WITH AORTIC REGURGITATION UNDERGOING THE ROSS PROCEDURE? IMPACT OF A TAILORED SURGICAL APPROACH

The Ross procedure provides several advantages in young and middle-aged adults requiring aortic valve replacement. However, in patients with aortic regurgitation, the Ross procedure has been associated with increased autograft dilatation and need for late reintervention. Importantly, it has been shown that late dilatation and reintervention can be predicted by early changes in autograft root dimensions. The aim of this study was to evaluate the impact of a tailored Ross technique in patients with aortic regurgitation versus aortic stenosis in stabilizing autograft root dimensions. From 2011 to 2018, 236 consecutive patients underwent a Ross procedure using a total root technique (46±7 years) with > one-year of follow-up. Specific measures included: replacement of the ascending aorta with a Dacron graft, trimming of the autograft at the sinotubular junction, an extra-aortic annuloplasty ring and strict blood pressure control for 6-12 months (<110mmHg SBP). Aortic root dimensions were prospectively measured on serial echocardiograms. Patients with aortic stenosis [AS group] (n=163; 69%) were compared to those with aortic regurgitation or mixed aortic disease [AR group] (n=73; 31%). Clinical and echo data (TTE) were prospectively collected into the Canadian Ross Registry. Mean follow-up was 27±11 months (100 % complete). Aortic dimensions were analyzed using mixed effect models. At four years, mean diameters of the annulus, sinuses of Valsalva and the sinotubular junction in the AR group were 24±1 mm, 37±1 mm and 33±1 mm respectively. Overall, there no significant differences in the rates of autograft annulus, sinuses of Valsalva and sinotubular junction dimension changes between the AS group and AR group at four years (p=0.55, p=0.28 and p=0.89). Nevertheless, in both groups, there was a statistically significant increase in the sinuses of Valsalva diameter from pre-discharge to six months postoperatively (31±1 to 33±1 mm in the AS group and 33±1 to 36±1 in the AR group; p=0.01 and p=0.03). This remained stable thereafter up to 4 years (Figure). There were no difference in the freedom from AR>2 and autograft reintervention between the two groups (p=0.99 and p=0.10). Our results demonstrate the efficacy of a tailored approach in mitigating clinically significant early autograft root dilatation following a full root Ross procedure in patients with aortic regurgitation. Up to four years after surgery, there were no clinical or echocardiographic differences between AR and AS patients. Further follow-up is needed to determine if this will translate into a decreased incidence of long-term reintervention.