title: Cardiac reoperations following the Ross procedure in children: spectrum of surgery and reoperation results.
abstract: OBJECTIVE
  The Ross procedure is the preferred aortic valve replacement (AVR) choice in small children. Nonetheless, it is a complicated surgery and there are concerns that subsequent cardiac reoperations are exceptionally complex and associated with high morbidity and mortality. We examine the surgical spectrum and report outcomes of cardiac reoperations in patients who had undergone the Ross procedure during childhood.
  
  
  METHODS
  Records of 227 consecutive children (<18 years old) who had undergone the Ross procedure at our institution from 1991 to 2004 were reviewed. Our patient cohort was 50 patients who underwent 58 cardiac reoperations following the Ross procedure during the follow-up. Time-related outcomes were analyzed.
  
  
  RESULTS
  From 1992 to 2009, 50 patients, 37 males (74%), underwent cardiac reoperation at a mean age of 15.6±5.2 years and a mean interval of 3.9±3.0 years following the Ross procedure. Risk factors for cardiac reoperation following the Ross procedure on multivariable analysis were rheumatic fever, aortic regurgitation, concomitant cardiac surgery, use of fresh homografts and earlier era of surgery. Overall, 32 (55%) reoperations were isolated procedures whereas 26 (45%) were more complex involving 2-4 simultaneous cardiac procedures. In total, 92 procedures were performed including AVR (n=31), homograft replacement (n=23), mitral valve replacement (n=18), mitral valve repair (n=11), tricuspid valve repair (n=5) and other (n=4). There was no operative mortality and one late death. Survival was 98% at 10 years. During the follow-up, 8 of 50 patients required further cardiac surgery following initial reoperation with freedom from additional cardiac surgery of 82% at 10 years. Subsequent cardiac surgery risk was higher in patients with pre-operative aortic regurgitation and those who had concomitant surgery at time of Ross on log-rank analysis. Among survivors, 96% are in New York Heart Association class I/II.
  
  
  CONCLUSIONS
  A wide range of cardiac reoperations may be required in children following the Ross procedure, especially those with underlying rheumatic aetiology, aortic regurgitation and multivalvular involvement. Despite complexity, reoperation following the Ross procedure can be performed with low mortality and good mid-term results. This information should be taken into consideration during the selection of aortic valve substitute in children.
authors.affiliation: The Heart Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. balsoufi@hotmail.com
authors.forename: Bahaaldin
authors.initials: B
authors.lastname: Alsoufi
authors.forename: Bahaa
authors.initials: B
authors.lastname: Fadel
authors.forename: Ziad
authors.initials: Z
authors.lastname: Bulbul
authors.forename: Mamdouh
authors.initials: M
authors.lastname: Al-Ahmadi
authors.forename: Majid
authors.initials: M
authors.lastname: Al-Fayyadh
authors.forename: Avedis
authors.initials: A
authors.lastname: Kalloghlian
authors.forename: Ghassan
authors.initials: G
authors.lastname: Siblini
authors.forename: Zohair
authors.initials: Z
authors.lastname: Al-Halees
mesh_terms: D000293:Adolescent; D000328:Adult; D001022:Aortic Valve Insufficiency / Q000151:congenital / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015999:Multivariate Analysis; D011664:Pulmonary Valve / Q000637:transplantation*; D012086:Reoperation; D012189:Retrospective Studies; D012214:Rheumatic Heart Disease / Q000401:mortality / Q000601:surgery; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D055815:Young Adult