title: Right ventricular outflow tract reconstruction in Ross patients: does the homograft fare better?
abstract: BACKGROUND
  In the Ross aortic valve replacement (AVR) procedure, the right ventricular outflow tract (RVOT) conduit is inserted in an orthotopic position. In complex congenital RVOT obstruction, the right ventricular-pulmonary artery (RV-PA) conduit is placed in a more heterotopic position. We hypothesized that durability of homograft RVOT reconstruction in the Ross AVR is improved secondary to orthotopic positioning and the ability to oversize the RV-PA homograft conduit in the Ross AVR.
  
  
  METHODS
  Between June 1993 and May 2007, 183 consecutive patients (mean age, 23.3 +/- 15.2; median, 22; range, 1 month to 61 years) underwent Ross AVR with RVOT reconstruction using a cryopreserved pulmonary homograft (n = 156), decellularized pulmonary homograft (n = 22), and bovine jugular vein conduit (n = 5).
  
  
  RESULTS
  Three patients died (2 early, 1 late; mean follow-up, 5.7 +/- 3.3 years). Twenty-four patients (13%) had a peak systolic RVOT gradient exceeding 20 mm Hg, 5 (3%) had a gradient exceeding 40 mm Hg, and 7 (4%) had more than 2+ RVOT insufficiency. Eight patients (4%) underwent conduit replacement for RV dysfunction. Freedom from RVOT reoperation at 10 years is 96%. Freedom from RV failure and dysfunction are 98% and 96% at 5 years and 96% and 93% at 10 years, respectively. Independent predictors of pulmonary homograft RV-PA conduit dysfunction are smaller (< 14 mm) RVOT conduit size (p = 0.03) and follow-up exceeding 5 years (p = 0.05).
  
  
  CONCLUSIONS
  Stenosis and regurgitation of the RV-PA conduit in adults and children following Ross AVR is infrequent. The most logical reasons for the superior performance of the homograft in Ross patients are: (1) orthotopic positioning, (2) older age of implant, and (3) the ability to significantly oversize the homograft in Ross patients.
authors.affiliation: Section of Cardiothoracic Surgery, James W. Riley Hospital for Children and Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA. jobrown@iupui.edu
authors.forename: John W
authors.initials: JW
authors.lastname: Brown
authors.forename: Mark
authors.initials: M
authors.lastname: Ruzmetov
authors.forename: Mark D
authors.initials: MD
authors.lastname: Rodefeld
authors.forename: Mark W
authors.initials: MW
authors.lastname: Turrentine
mesh_terms: D000293:Adolescent; D000328:Adult; D001021:Aortic Valve / Q000601:surgery*; D001705:Bioprosthesis; D002648:Child; D002675:Child, Preschool; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D011651:Pulmonary Artery / Q000637:transplantation*; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D014694:Ventricular Outflow Obstruction / Q000601:surgery*