Children undergoing aortic valve replacement had improved short-term and long-term outcomes with pulmonary autograft (Ross procedure) compared to mechanical or tissue AVR procedures, according to the results of a retrospective study presented Tuesday at Scientific Sessions. Amber Leila Sarvestani, a third-year medical student at the University of Missouri-Kansas City, presented the research.
Based on the study’s results, clinicians may need to revisit this issue and give more consideration to the Ross procedure, according to senior author Lazaros Kochilas, MD.
“Even after adjustment for a patient’s age, era effect and co-existing conditions, the Ross procedure still seems to be holding its place as the more favorable choice compared with any of the other choices,” said Kochilas, medical director of cardiac clinical research at Children’s Healthcare of Atlanta.
The study was designed to compare long-term, transplant-free survival of children undergoing AVR with several procedures: pulmonary autograft, mechanical valve or tissue valve prosthesis. The Ross procedure, or pulmonary autograft, is a more complex surgery; it involves replacing the diseased aortic valve with the patient’s own pulmonary valve and then placing a pulmonary allograft in the right ventricular outflow and re-attaching the coronary arteries to the neoaorta.
In the study, the researchers looked at data from Pediatric Cardiac Care Consortium, a large multi-institutional, U.S-based registry of interventions for congenital heart diseases. The study included 1,068 children who had undergone their first AVR after 1991.
The median age of the children in the study was 12.7 years. The most common AVR procedure in the study cohort was the Ross procedure (44 percent) followed by mechanical valve replacement (40 percent) and then tissue prosthesis (16 percent). The in-hospital mortality was lowest for Ross procedures (3.1 percent), followed by mechanical replacement (4.9 percent). It was highest in patients undergoing tissue prosthesis (11.9 percent).
Of the 1,037 patients that survived to discharge, the transplant-free survival up to 15 years was 92.9 percent for those who underwent a Ross procedure, 84 percent for mechanical procedure and 77.6 percent for tissue prosthesis.
There was increased long-term survival for patients after the Ross procedure compared with mechanical or tissue valve replacement with increasing advantage five years after the AVR procedure. A multivariable analysis showed that outcomes with the Ross procedure were still three times better than with the mechanical valve.
The results are encouraging, Kochilas said, because the Ross procedure is associated with improved quality of life compared to the other AVR procedures.
“An additional benefit to the autograft is the low risk for blood clots and, thus, no need for anticoagulation, which can have big implications for children’s quality of life,” Kochilas said. “With the mechanical valve, children need to take blood thinners, which can be very demanding as it requires frequent blood tests and dose adjustment, and it imposes dietary restrictions and limits participation in certain physical activities.”