title: Incidence, location, pathology, and significance of pulmonary homograft stenosis after the Ross operation.
abstract: BACKGROUND
  The Ross operation has several theoretical advantages. However, concern exists regarding evolving pathology in the pulmonary homograft.
  
  
  RESULTS
  Consecutive patients (n=144; mean age 31 years, range 2 months to 64 years) undergoing the Ross operation were studied between 1993 and 2000. Echocardiographic examination of the pulmonary homograft was performed immediately after surgery, then at yearly intervals for a mean interval of 48 months. Fifteen patients (mean age 37 years) in whom echocardiography revealed peak pulmonary gradients >/=30 mm Hg (mean 46+/-18 mm Hg) underwent MRI with velocity mapping in a Picker 1.5-T magnet. No patient had more than mild pulmonary regurgitation. Four patients required reoperation for rapidly progressive pulmonary homograft stenosis; in all 4, there was macroscopic and microscopic evidence of a pronounced chronic adventitial reaction, with perivascular infiltration producing extrinsic compression. Freedom from any pulmonary homograft stenosis at 7-year follow-up was 79.7%, with instantaneous hazard falling to zero after 4 years. Freedom from reoperation at 7 years was 96.7%. In those studied with MRI, there was evidence of narrowing of the whole homograft or distal suture line in 14 of 15 patients, with obvious excess surrounding tissue in 11. Mean minimum diameter and peak velocity by MRI were 11+/-2 mm and 3.2+/-0.7 m/s, respectively. Multivariate analysis of patient-, surgery-, and homograft-related variables did not reveal any significant risk factors for development of neopulmonary stenosis.
  
  
  CONCLUSIONS
  Pulmonary homograft stenosis after the Ross operation is clinically important and appears to represent an early postoperative inflammatory reaction to the pulmonary homograft that leads to extrinsic compression and/or shrinkage.
authors.affiliation: Department of Cardiology, Cardiovascular Magnetic Resonance, National Heart and Lung Institute, Royal Brompton Hospital, London, UK. g.carr-white@virgin.net
authors.forename: G S
authors.initials: GS
authors.lastname: Carr-White
authors.forename: P J
authors.initials: PJ
authors.lastname: Kilner
authors.forename: J K
authors.initials: JK
authors.lastname: Hon
authors.forename: T
authors.initials: T
authors.lastname: Rutledge
authors.forename: S
authors.initials: S
authors.lastname: Edwards
authors.forename: E D
authors.initials: ED
authors.lastname: Burman
authors.forename: D J
authors.initials: DJ
authors.lastname: Pennell
authors.forename: M H
authors.initials: MH
authors.lastname: Yacoub
mesh_terms: D000328:Adult; D001022:Aortic Valve Insufficiency / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000706:statistics & numerical data*; D015897:Comorbidity; D003710:Demography; D018450:Disease Progression; D018572:Disease-Free Survival; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000453:epidemiology* / Q000473:pathology*; D006801:Humans; D015994:Incidence; D008279:Magnetic Resonance Imaging; D008297:Male; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology / Q000473:pathology; D016016:Proportional Hazards Models; D011664:Pulmonary Valve / Q000000981:diagnostic imaging / Q000637:transplantation*; D011666:Pulmonary Valve Stenosis / Q000175:diagnosis / Q000453:epidemiology; D012086:Reoperation / Q000706:statistics & numerical data; D018570:Risk Assessment; D014184:Transplantation, Homologous