title: The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.
abstract: OBJECTIVE
  It is hypothesized that by performing radical aortic root manipulation and then autologous support for the pulmonary autograft in the Ross procedure, this will maintain aortic root size and should, in turn, lead to the demonstrated low incidence of late aortic regurgitation and need for reoperation on the aortic root and valve.
  
  
  METHODS
  Aortic root size was measured echocardiographically both preoperatively and then at second yearly intervals in 322 consecutive patients who underwent a Ross operation between October 1992 and June 2013 with autologous support of the pulmonary autograft root using the patient's own aorta. This technique, a variant of the inclusion cylinder method, has been developed with the aim of minimizing prosthetic materials in the aortic root.
  
  
  RESULTS
  Measures to reduce aortic root size included annulus reduction in 201 patients (62.4%) and reduction in aortic sinus or sinotubular junction in 159 patients (49.4%). Maximal aortic root diameter postoperatively at 5, 10, and 15 years was 34.0, 34.6, and 34.7 mm, respectively. Eleven reoperations were required during the study period for progressive aortic regurgitation (none for aortic root enlargement), with freedom from reoperation being 96% at both 15 years and 18 years. Preoperative pure aortic regurgitation, aortic annulus, and sinotubular junction enlargement were risk factors for reoperation.
  
  
  CONCLUSIONS
  This inclusion method of pulmonary autograft implantation leads to minimal increases in aortic root size over time, with no reoperations for aortic root dilatation and a low requirement for aortic valve reoperation. The Ross procedure deserves to remain on the surgical menu for aortic valve replacement.
authors.affiliation: Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia; Department of Cardiothoracic Surgery, Epworth Hospital, Melbourne, Australia; Department of Surgery, University of Melbourne, Parkville, Australia. Electronic address: peter.skillington@mh.org.au.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Skillington
authors.affiliation: Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: M Mostafa
authors.initials: MM
authors.lastname: Mokhles
authors.affiliation: Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Johanna J M
authors.initials: JJ
authors.lastname: Takkenberg
authors.affiliation: Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia; Department of Cardiothoracic Surgery, Epworth Hospital, Melbourne, Australia; Department of Surgery, University of Melbourne, Parkville, Australia.
authors.forename: Marco
authors.initials: M
authors.lastname: Larobina
authors.affiliation: Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: O'Keefe
authors.affiliation: Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia; Department of Nursing, University of Melbourne, Parkville, Australia.
authors.forename: Rochelle
authors.initials: R
authors.lastname: Wynne
authors.affiliation: Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia; Department of Surgery, University of Melbourne, Parkville, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Tatoulis
mesh_terms: D000293:Adolescent; D000328:Adult; D001014:Aortic Aneurysm / Q000209:etiology / Q000601:surgery; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000601:surgery*; D064592:Autografts; D001705:Bioprosthesis; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D011651:Pulmonary Artery / Q000637:transplantation*; D011664:Pulmonary Valve / Q000637:transplantation*; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult