outcomes following simple and complex (damus- kaye-stansel takedown) ross operations in 62...
TRANSCRIPT
Outcomes following simple and complex (Damus-Kaye-Stansel takedown) Ross operations
in 62 consecutive pediatric patients
Alejandra Bueno MD, David Zurakowski PhD, Vijayakumar Raju MD, Michele J. Borisuk MSN, CPNP, Suyog A. Mokashi MD, Sitaram Emani, MD, Gerald R.
Marx MD, Pedro J. del Nido MD, and Christopher W. Baird MD
No disclosures
Introduction
The Ross operation has good outcomes in selected pediatric patients with a biventricular circulation.
However, there have been no reports in patients with uni-ventricular circulation who have undergone single ventricle palliation followed by biventricular conversion with Ross operation.
Objectives
Review outcomes following simple and complex Ross operations including patients undergoing biventricular conversion with Damus-Kaye-Stansel (DKS) takedown.
To determine predictors for successful Ross operation based on echocardiographic measurements.
Methodology
A retrospective review on 62 patients who underwent Ross operations at Boston Children's Hospital from March 2000 and October 2014.
Simple (50 pts.) – Ross operation in patients who had a biventricular circulation.
Complex (12 pts.) –Patients with pre-operative uni-ventricular circulation with hypoplasia of the left heart structures who then underwent biventricular conversion with DKS takedown and a Ross operation.
Data collectionClinical data
IRB approval was obtained.Medical records were reviewed.
EchocardiographyData was measured independently by a single reviewer
and a random sample was reviewed by a second reviewer.
Echocardiography
Aortic Annulus Ascending Aorta
Sinus of Valsalva
Measurement of Vena Contracta
Aortic regurgitation was estimated from the vena contracta width indexed to the square root of the body surface area.
Patient Characteristics
Follow-up All patients (n=62 patients)
Follow-up was available in 54 patients (87%) At a median of 2.7 years (IQR, 8m-5.2 years)
Simple group (n=50 patients) Follow-up was available in 45 patients At a median of 42 months (IQR, 8m-66m)
Complex group (n=12 patients) Follow-up was available in 11 patients At a median of 18 months (IQR, 9m-41m)
Time Since Ross Operation (months)
0 6 12 18 24 30 36 42 48 54 60 66
Pa
tie
nt
Su
rviv
al
(%)
0
10
20
30
40
50
60
70
80
90
100
Complex Group (2 deaths in 12 patients)
Simple Group (0 deaths in 50 patients)
Group difference: P = .004, log-rank test = 8.30
(50) (36) (34) (28) (23) (16)(12) (8) (5) (4) (3) (2)
Median (IQR) Follow-up:Simple Group: 42 months (8-66)Complex Group: 18 months (9-41)
Patient Survival
Time Since Ross Operation (months)
0 6 12 18 24 30 36 42 48 54 60 66
Fre
ed
om
fro
m n
eo
-Ao
Va
lve
R
e-i
nte
rve
nti
on
(%
)
0
10
20
30
40
50
60
70
80
90
100
Complex Group (0 events in 12 patients)
Simple Group (2 events in 50 patients)
No group difference: P = .63, log-rank test
Median (IQR) Follow-up:Simple Group: 42 months (8-66)Complex Group: 18 months (9-41)
Freedom from Neo-aortic Valve Re-intervention
Pre
op
era
tive
Ec
ho
Z-s
co
res
-4
-3
-2
-1
0
1
2
3
4
P = .25
P = .04
P = .13
Simple GroupComplex Group
Sinus of Valsalva Aortic Annulus Ascending Aorta
Pre-operative Echocardiography Z-scores
Aortic annulusEchocardiographic Z-scores
Sinus of Valsalva Echocardiographic Z-scores
Aortic regurgitation – Vena contracta - Indexed to BSA (mm/m)
Baseline Pulmonary Valve Z-score
-3 -2 -1 0 1 2 3 4 5
Lat
e F
oll
ow
-up
Ao
rtic
Reg
urg
itat
ion
(
Ven
a C
on
trac
ta -
In
dex
ed t
o B
SA
)
0
1
2
3
4
5
6
Complex Group, r = -0.15, P = .67
Simple Group, r = -0.08, P = .64
Lack of correlation between initial pulmonary valve
Z-scores and late aortic regurgitation.
Pre-operative Pulmonary Valve Z-score
LimitationsRetrospective
Single center study
Patient selection bias - as patients with large dilated aortic roots and ascending aortas were generally not operated with a Ross procedure.
Complex group of patients with multiple additional lesions.
ConclusionsThe aortic valve complex including the aortic annuli, the
sinus of Valsalva and ascending aorta increased in size without development of late aortic regurgitation.
Neither pulmonary valve size or native pulmonary and aortic annular size discrepancy should be a contraindication for Ross procedure.
The Ross operation should be considered in patients with significant aortic valve disease undergoing biventricular conversion with DKS takedown.
Baseline Pulmonary Valve Z-score
-3 -2 -1 0 1 2 3 4 5
Lat
e F
oll
ow
-up
Ao
rtic
Reg
urg
itat
ion
(
Ven
a C
on
trac
ta -
In
dex
ed t
o B
SA
)
0
1
2
3
4
5
6
Complex Group, r = -0.15, P = .67
Simple Group, r = -0.08, P = .64
No correlation between base line PV Z-score and late follow-up aortic regurgitation.
Figure 3C
Time Since Ross Procedure (months)
0 6 12 18 24 30 36 42 48 54 60 66 72
Fre
ed
om
fro
m R
VO
T R
e-in
terv
enti
on
(%
)
0
10
20
30
40
50
60
70
80
90
100
Kaplan-Meier 5-Year Freedom from Re-intervention (95% CI) RVOT Surgical: 83% (72-94%) RVOT Cath: 87% (76-98%) RVOT Surgical or Cath: 71% (58-84%)
RVOT Surgical Re-interventions (n = 7)RVOT Cath Re-interventions (n = 6)RVOT Surgical or Cath Re-interventions (n = 13)
(62) (44) (39) (32) (26) (18) (10)
Time Since Ross Operation (months)
0 6 12 18 24 30 36 42 48 54 60 66
Fre
edo
m f
rom
RV
OT
Su
rgic
al
or
Ca
th
Re-
inte
rven
tio
n (
%)
0
10
20
30
40
50
60
70
80
90
100
(50)(12)
(36)(8)
(34)(5)
(28)(4)
(23)(3)
(16)(2)
Figure 3D
Complex Group (3 events in 12 patients)
Simple Group (10 events in 50 patients)
No group difference: P = .22, log-rank test
Figure 4A
Ascending Aorta Z-score (Pre-Echo)
-6 -4 -2 0 2 4 6
Asc
end
ing
Ao
rta
Z-s
core
(L
ate-
Ech
o)
-6
-4
-2
0
2
4
6
Simple Group Complex Group r = 0.00, P = .98
Aortic Root Z-score (Pre-Echo)
-6 -4 -2 0 2 4 6
Ao
rtic
Ro
ot
Z-s
core
(L
ate-
Ech
o)
-4
-2
0
2
4
6
8
10
Simple Group Complex Group r = 0.38, P = .007
Figure 4B
Online table 2. Echo measurements.
Online table 3. Late outcomes.
Preop D/C Follow-up Preop D/C Follow-up
AA
Z-s
core
-3
-2
-1
0
1
2
3
4
5
6
Complex Group
Simple Group
P = .22
P = .74
Improvement in AA Z-score between discharge and late follow-up
Preop D/C Follow-up Preop D/C Follow-up
AA
Z-s
core
-3
-2
-1
0
1
2
3
4
5
6
Complex Group
Simple Group
P = .22
P = .74
Improvement in AA Z-score between discharge and late follow-up
P = .27