Background: Patients with bicuspid aortic valves (AV) are suspected to have weaker connective tissue than patients with normal AVs, resulting in higher rates of late aortic dilatation or aneurysm. If the pulmonary valve of such patients is used as autograft in Ross patients, this tissue weakness might affect durability of the pulmonary valve in aortic position.

Introduction: Autograft and homograft endocarditis remain a concern after the Ross procedure. Aim of the present study was to identify the incidence and characteristics of autograft and homograft endocarditis in the adult population of the German-Dutch Ross Registry.

Introduction: Reinterventions after the Ross procedure remain a concern for patients as well as treating physicians. Aim of the present study was to provide an update on reinterventions after the Ross procedure in the large patient population of the German-Dutch Ross Registry

Until today, no perfect valve substitute has been developed. Some essential requirements for a perfect valve substitute are proposed in Table 1. Regarding the aortic valve, the Ross procedure (pulmonary autograft operation) is closer to this ideal than any other substitute in many ways. For this reason, it was enthusiastically adopted by many surgeons after it became widely known in the late 1980s and was technically simplified by Stelzer and Elkins [27] (total root replacment, Fig. 1). In recent years, however, several groups report high reoperation rates and a worrysome tendency for the development of neoaortic regurgitation and/or ascending aortic aneurysms [7, 10, 16, 18, 20, 29]. A recent systematic review concluded that "durability limitations become apparent by the end of the first postoperative decade, in particular in younger patients" [28], and it was asked whether the ross procedure is a "Trojan horse" [15]. As a result of these newer data, many centers appear to have stopped performing the Ross procedure.

Aims: The Ross operation presents with favourable postoperative hemodynamics and clinical results. Usage of a pulmonary homograft (HG) is associated with an elevated risk of valve substitute pathology. This study was conducted in order to evaluate the clinical development of the HG in a large international Ross operated cohort.

Objectives: Patients with a bicuspid aortic valve (BAV) often present with aortic root and ascending aorta pathology. Usage of the Ross operation in this subgroup of pts remains controversial regarding the development of aortic regurgitation (AR) and aortic root dimensions (ARD). Comparing BAV and non-BAV with respect to AR and ARD has rarely been performed.

Aims: The Ross Operation is a complex double valve procedure for aortic valve replacement. The benefit of a physiological, anticoagulant free autogenous aortic valve substitute is weighed against two valves subsequently at risk and potential further operations.

Objectives: In the time course after the ROSS procedure development of autograft regurgitation (AR) is a potential hazard of clinical impact. We reviewed our experience with the ROSS procedure to identify development of autograft regurgitation over time for two different techniques of autograft implantation.

Background: Younger patients are generally regarded as target group for the Ross-Operation. Limited homograft availability has traditionally limited the permitted age for recipients. We justified our policy of older recipients on the grounds of an increase in general life expectancy and a more active ageing population.

Background— Return of left ventricular mass to normal is considered to be a favorable result of aortic valve replacement. The Ross procedure provides near normal hemodynamics and thus allows studies of left ventricular (LV) reverse remodeling. LV mass regression may be influenced by surgical technique (subcoronary [SC] versus root replacement [RR]). Methods and Results— Data from the German Ross Registry were analyzed. A total of 646 patients (mean age: 43.6±12.7 years, range: 16 to 71 years; SC technique n=295, RR technique n=351) underwent a Ross procedure in 7 participating centers from 1990 to 2004. The patients underwent preoperative and postoperative echocardiographic evaluations. Mean follow-up time was 3.5±2.5 years (range 0.12 to 13.7 years). Follow-up completeness was 97%. The LV mass index (LVMI) decreased significantly during follow-up in both groups (SC: 209±53 preoperatively to 154±48 at 1-year follow-up, [ P <0.01 versus preoperative values] to 149±51g/m 2 at 2-year follow-up, [ P =NS 1-year versus 2-year follow-up] versus RR: from 195±56 preoperatively to 144±51 at 1-year follow-up [ P <0.01 versus preoperative values] to 140±49g/m 2 [ P =NS 1-year versus 2-year follow-up]). LVMI regression remained stagnant 1 year after the Ross procedure in most patients in both groups. On the basis of multivariate analysis, predictors for incomplete LVMI regression after the autograft procedure were high preoperative LVMI, smoking, and uncontrolled diastolic hypertension. Conclusions— At mid-term echocardiographic follow-up, patients of both groups had favorable autograft hemodynamics. Risk factors for incomplete postoperative LVMI regression in our study were smoking and persistent diastolic hypertension. This emphasizes the importance of cessation of smoking and treatment of arterial hypertension, even in younger patients, after corrected aortic valve disease.

Purpose. We present an early series to determine the technical feasibility of simultaneous aortic valve and complete ascending aortic replacement using a longer stentless aortic xenograft, harvested with an extended root.Description. The stentless xenograft valved conduits commercially available are too short for complete ascending aorta replacement, and usually a prosthetic tube graft is required distally.Evaluation. To avoid this extra prosthetic conduit distally a number of stentless aortic xenografts with extended conduit were obtained from a supplier (Medtronic Inc). They were inserted in 6 elderly patients (67.8 +/- 7.1 years) who all required aortic valve and ascending aorta replacements owing to pathologic dilation.Conclusions. In all cases an extra prosthetic conduit was avoided, and the length of the available biological conduit comfortably allowed total ascending aortic replacement without tension. The advantages therefore were one less suture line, cost saving regarding the prosthetic conduit, shorter cross-clamping time, and possibly shorter time spent on hemostasis. (C) 2004 by The Society of Thoracic Surgeons.

BACKGROUND:The Ross operation has an established position in young patients. We address the question of whether any age group profits most from the Ross operation, and we compare the results in various ages. METHODS:From February 1995 to August 2001 we performed 250 Ross operations. Group 1 consisted of 46 patients, ages 2 to 25 years (median age, 15 years). Group 2 consisted of 123 patients, ages 26 to 49 years (median age, 39 years). Group 3 consisted of 81 patients, ages 50 to 67 years (median age, 55 years). Echocardiography was performed perioperatively, at 2 to 6 months, and then yearly. RESULTS:Mean follow-up for the three groups was 32, 31, and 28 months, respectively (p = 0.36). One patient from group 2 died after 25 months caused by suppurative pneumonia and 3 patients from group 3 died (1 from suspected acute thoracic aorta dissection at 40 months, 1 from ventricular fibrillation after 25 months, and 1 from an undiagnosed sudden death at 5 months). Autograft replacement was necessary for 3 patients from group 2 and 1 from group 3. Autograft repair was necessary for 1 patient from group 2, and pulmonary homograft reoperation was necessary for 1 patient from group 1. All other autografts currently have physiologic gradients and clinically insignificant regurgitation. Median peak gradient across the right ventricular outflow tract was 23.6 +/- 18 mm Hg for group 1, 14.6 +/- 8 mm Hg for group 2, and 11.5 +/- 7 mm Hg, which was significantly lower for group 3 patients (p < 0.001). Eleven patients are under close follow-up for right ventricular outflow tract gradients > or = 40 mm Hg; eight of these patients are from group 1, 3 are from group 2, and there are none from group 3. CONCLUSIONS:Although the Ross operation provides excellent results in all age groups, the problem of right ventricular outflow tract stenosis has not been seen in patients older than 50 years, which implies that it offers superior results for aortic valve disease in middle aged and older patients.

Starting in November 1999, we performed a left atrial radiofrequency ablation procedure concomitantly to a variety of cardiac surgical procedures. By January 2001, this ablation procedure had been performed on 100 patients (age 65.7 +/- 10.4 years, 53 % male, 47 % female, left atrium 51.0 +/- 7.5 mm) suffering either from chronic or paroxysmal atrial fibrillation. Primary cardiac pathology was mitral valve disease in most cases (43), aortic valve disease (28) or coronary heart disease (27). After bilateral pulmonary veins isolation, an additional ablation line was directed from the left pulmonary veins to the mitral valve annulus (Thermaline probe, Boston Scientific Corporation, USA). Finally, the left atrial appendage was resected. Surgical success was evaluated in the immediate postoperative course, 3 and 6 months postoperatively (ECG and echocardiography), and every year after that. Operative time was 229.7 +/- 56.5 min, ablation time 18.8 +/- 6.9 min. Follow-up is 95 % complete at the time of writing. Mean follow-up time was 7.3 months, ranging from 3 to 23 months. Success (sinus rhythm and atrial contraction) was proven in 72 out of 90 patients (80.0 %) (75.0 % mitral valve surgery, 84.0 % other cardiac surgery). The reported results support a broad spectrum of indications for this left atrial ablation procedure.

BACKGROUND AND AIM OF THE STUDY:The Ross operation, introduced more than 30 years ago, has recently undergone several modifications to improve both technical feasibility and results. At the authors' institution, the Ross operation, performed as root replacement in all cases, was commenced in February 1995.METHODS:A total of 225 patients (177 males, 48 females; mean age 39+/-15 years; range: 2 to 67 years) were operated on up to December 2000. Aortic regurgitation was present in 80 patients, stenosis in 69, and combined disease in 73; prostheses were replaced in three patients. Combined procedures were performed in 51 patients. Nine patients had active endocarditis. Follow up was 98% complete and totaled 471 patient-years.RESULTS:There was no early mortality, and no thromboembolic or hemorrhagic events. Complications included prolonged ventilation in two patients, perioperative myocardial infarction in three, pacemaker implants in three and perioperative bleeding in six. One patient died at 25 months from hemoptysis, and one at five months of unknown cause. In the long term, four patients required reoperation due to autograft regurgitation (one autograft repair, three autograft replacements). Routine aortic annulus support, a lowered threshold in replacing all dilated ascending aorta and keeping the autograft short to the level of the sinotubular junction seems to have prevented further autograft failure. Pulmonary homograft stenosis led to reoperation in one patient. Six patients with elevated gradients are currently under observation. Echocardiography revealed autograft median peak gradients of 5.1+/-2.8 mmHg, pulmonary homograft gradients of 14.2+/-11.5 mmHg, and no significant regurgitation, except in one additional patient with recently diagnosed aortic insufficiency (grade >2).CONCLUSION:Mid-term excellent hemodynamic results, low morbidity and reoperation requirement support the evolved root replacement technique and justify its further utilization.

Background: In this report we address the question whether the Ross operation can be recommended in combined and complicated cardiac procedures. Methods: From February 1995 to July 2000, we performed 203 Ross operations, 129 with ideal clinical presentation (group 1: mean age 41 +/- 13 years, male 105). In 74 patients, the clinical presentation was complex (group 2 mean age 35 +/- 17 years, male 57), defined as previous aortic or cardiac operations in 32, active endocarditis in 8 or combined procedures in 40 patients. Follow-up is 95% complete. Results: Neither early mortality nor thromboembolic events were observed. Complications in group 1 vs. group 2 were prolonged ventilation in 1 vs. 1, pacemaker insertion in I vs. 2, minor myocardial infarction in none vs. 2 and postoperative bleeds in 2 vs. 3 patients. In group 1, one patient died of hemoptysis at 25 months, and in group 2 one sudden death occurred at 5 months. In the long term, two patients required reoperation for autograft failure in group 1, and one on group 2. Pulmonary stenosis required surgical treatment in one patient of group 2. Echocardiography revealed physiological gradients across the autograft with no significant regurgitation in either group. Conclusion: The Ross operation has excellent mid-term results and is a safe and attractive therapeutic approach, both in combined procedures and complex clinical presentations.

Background. The Ross operation approaches the ideal aortic valve replacement. Between February 1995 and February 2000 we performed 186 procedures. This article reviews modifications introduced reflecting our experience.Methods. In all patients the Ross operation was performed as root replacement. Echocardiographic follow-up was complete in 94% of patients.Results. No operative death or early mortality occurred, nor did thromboembolic or hemorrhagic events. One patient died at 25 months from hemoptysis with pulmonary valve vegetations. Three patients required reoperation for autograft insufficiency. In 1 patient a tethered cusp was repairable and in 2 patients progressive autograft dilatation required autograft replacement. After routinely incorporating support into the aortic annulus and replacing all dilated ascending aorta, autograft dilatation did not recur. For the pulmonary homograft, one outflow patch was placed to relieve a symptomatic gradient. Nine patients with elevated gradients were under observation. Echocardiography revealed autograft median peak systolic gradients of 4.6 +/- 2.8 mm Hg, pulmonary homograft gradients of 14.8 +/- 9.6 mm Hg, and nil or insignificant regurgitation.Conclusions. The aortic annulus must be supported and the dilated ascending aorta replaced. Root replacement with a short autograft allows consistent results. Pulmonary homograft dysfunction is rare but unpredictable. (C) 2001 by The Society of Thoracic Surgeons.

The pulmonary autograft as aortic valve replacement has normal haemodynamic performance, can grow, and the patient does not require anticoagulation. The technical demands of the operation and the two valves at risk have delayed acceptance. A review of a single surgeon's experience in 100 consecutive patients (20 female, 80 male) operated on in Europe between February 1995 and February 1998 is presented. Patient ages ranged from 8 to 60 years (median 40.5 years). Aortic stenosis was the primary aortic valve pathology in 34 patients, incompetence in 25 and combined disease in 41. The operation was a redo procedure in 14 patients, and combined cardiac procedures were undertaken in 16. Follow-up has been complete to date. There have been no early or late deaths. No thrombo-embolic events or endocarditis have occurred. Two patients have required reoperation due to valve dysfunction, one adult patient required late reoperation due to progressive annular dilation with incompetence of the pulmonary autograft, and a child required revision of the pulmonary homo-graft due to progressive stenoses of the homograft.Echocardiographic evaluation reveals trivial or no aortic regurgitation in 89 patients and the remaining II have clinically insignificant insufficiency, graded as minimal. None of the pulmonary homografts in the right ventricular outflow tract have significant insufficiency. The median peak systolic gradient across the pulmonary autograft (aortic valve) is 7.5 mmHg (standard deviation (SD) 3.4 mmHg, range 3 - 22), and for the pulmonary homograft on the right of the heart a median peak gradient of 8.8 mmHg (SD 4.7) range 3 - 30 mmHg was documented. A progressive increase in pulmonary homograft valve gradients has been seen in two children, one of whom has required reoperation.Excellent results are obtainable in the Ross operation, as shown by 100 consecutively operated patients without mortality or thrombo-embolic or haemorrhagic events. Owing to the unique advantages offered by a living and functionally normal aortic valve substitute without the need for systemic anticoagulation the procedure deserves greater application, particularly in the economically disadvantaged societies of the developing world without sophisticated medical infrastructures.