EARLY AND LATE PERSPECTIVES OF THE ROSS … · • Ross-Konno 955,562 ,988 ,000 ... Pasquali SK ,...
Transcript of EARLY AND LATE PERSPECTIVES OF THE ROSS … · • Ross-Konno 955,562 ,988 ,000 ... Pasquali SK ,...
EARLY AND LATE PERSPECTIVES OF THE ROSS(ROSS/KONNO) OPERATION IN PEDIATRIC POPULATION:AN ITALIAN MULTI-CENTRIC STUDY.
EARLY AND LATE PERSPECTIVES OF THE ROSS(ROSS/KONNO) OPERATION IN PEDIATRIC POPULATION:AN ITALIAN MULTI-CENTRIC STUDY.
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
G. Lucchese1, A. Carotti2, G. Brancaccio2, P.A. Abbruzzese3, G. Caianiello4, A.Frigiola5, G.D. Gargiulo6, L. Galletti7, S.M. Marianeschi8, A. Mazzucco1, B.Murzi9, C.N. Pace6, M. Pozzi10, L. Zannini11, G.B. Luciani1.
1Verona/IT, 2Rome/IT, 3Turin/IT, 4Monaldi H., Naples/IT, 5San Donato Milanese,Milan/IT, 6Bologna/IT, 7Bergamo/IT, 8Niguarda H., Milan/IT, 9Massa/IT,10Ancona/IT, 11Genova/IT.
None of the authors has any affiliation, financial agreement, or other involvement with any
company to disclose.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Disclosure
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Niguarda H. (Milan)
O.I.R.M. S. Anna (Turin)
Ospedale Pediatrico (Genova)
G.Pasquinucci H. (Massa)
O.P.B.G. (Rome)
Monaldi H. (Naples)
S. Orsola-Malpighi H. (Bologna)
Ospedali Riuniti (Ancona)
University Hospital (Verona)
Ospedali Riuniti (Bergamo)Ospedale Policlinico S. Donato (Milan)
Centers
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
The Ross Procedure (Indications)1. Hypoplasia of the aortic valve annulus in the neonate2. Progressive stenosis of the aortic valve in infants and
children3. Multilevel left ventricular outflow tract obstruction in
association with aortic valve stenosis not amenable to aortic valve repair that requires enlargement of the outflow tract
4. Aortic insufficiency as a complication of percutaneous balloon aortic valvuloplasty
5. Aortic valve endocarditis
Background
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Background
Cox proportional hazard model, younger age among children (hazard ratio [HR] per year, 0.86; 95% CI, 0.80–0.93; P0.0001), older age
among adults (HR per year, 1.04; 95% CI, 1.02– 1.06; P0.0001), and presence of preoperative risk factors (HR, 1.38; 95% CI, 1.05–1.83;
P0.023) were associated with increased risk for late mortality.
95,0 % (1) 94,4 % (5) 92,5 % (10) 98,6 % (1) 96,9 % (5) 94,7 % (10)
Early (<30 days) mortality 1.2%.
Sievers HH, Circulation 2010Sievers HH, Circulation 2010
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Background
1. A total of 24 patients younger than 1 year of
age
2. Age at operation ranged from 1 to 236 days
(median 28 days)
3. The median follow-up period was 81 months
(range 1–173 months)
4. 23 reoperations or reinterventions
performed after Ross-Konno operation
5. 14/23 consisted of RV-PA conduit
replacement.
Pulmonary autografts demonstrated gooddurability with low mortality and morbidity.
Maeda K, Ann Thorac Surg 2012Maeda K, Ann Thorac Surg 2012
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Background
1. 121 patients2. Median age at
the Ross procedure was 8.2 years (4 days to 34 years)
Pasquali SK, JTCVS 2007Pasquali SK, JTCVS 2007
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
To define current outcome after Rossoperationfrom infancy to adolescencea multi-center observational studycovering 22 years of surgicalexperience was undertaken.
Objective
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
• Period of study 1990-2012
• Retrospective Study
• 11 Italian Pediatric Cardiac Units
• Descriptive and Kaplan-Meier analysis definedoutcome
• Cox regression identified risk factors
Methods
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Patient’s Characteristics
N° 292
Median Age (Min.-Max.)• Age < 1 years old (%)
10 years (2 days to 18 years)35 (12%)
Indications:- Aortic stenosis (+/- sub-aortic)- Aortic regurgitation- Combined disease
10310485
Prior cardiac surgery 35% (104/292)
Techniques of operation:- Root- Root inclusion- Sub-coronary- Ross-Konno
196131667
Methods
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
The Ross Procedure Technique (Root)
Background
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
The Ross Procedure Technique (Variants)
Ross Operation: Root Inclusion Technique
Ross Operation: Sub-Coronary Technique
Background
Ross - Konno
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Results
Early deaths N°10 (3.4%)
Median follow-up (min. – max.): 80.93 months (1.67 – 267.33 months)
5 years 93.2±1.5%
10 years 92.0±1.7%
15 years 82.8±8.9%
Late deaths N°12
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Survival Stratified By Age
Median follow-up (min. – max.): 80.93 months (1.67 – 267.33 months)
Results
Neonates/Infants
Children/Adolescents
p=0,000
Deaths
Neonates/Infants
N° 14/24
Deaths
Children/Adolescents
N° 8/268
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Results
5 years 95.7±1.3%
10 years 87.7±2.5%
15 years 73.3±7.2%
Left Heart Reoperations
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Results
5 years 92.6±1.7%
10 years 83.1±2.9%
15 years 72.6±9.0%
• Overall 35 (12%)right-heart conduitreplaced
• Overall 35 (12%)right-heart conduitreplaced
Right Heart Reoperations
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Results
SE Sig. HR
Technique: • Sub-Coronary ,606 ,044 ,296 • Root Inclusion 852,248 ,987 ,000 • Ross-Konno 955,562 ,988 ,000
Indication:
• Aortic Stenosis ,520 ,868 1,091 • Aortic Regurgitation ,735 ,798 1,206
Prior Cardiac Operation
,514 ,906 1,063
Age < 4 months
,511 ,000 17,147
Hazard Cox Analysis Risk Factors
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Results
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
(*)The most of patients do not assume anticoagulation therapy
(**) 2,6% of women had pregnancy
• Ross operation is associated with excellent very long-term survival in a population of high risk infants and children with congenital aortic valve and complex LVOT disease
• Contrary to expectations, risk of autograft reoperation increases significantly 15 years after Ross and is similar to risk of right heart reoperation
• When performed in neonates and young infants (< 4 months), the Ross or Ross-Konno carries incremental hospital risk
• Ross operation is associated with excellent very long-term survival in a population of high risk infants and children with congenital aortic valve and complex LVOT disease
• Contrary to expectations, risk of autograft reoperation increases significantly 15 years after Ross and is similar to risk of right heart reoperation
• When performed in neonates and young infants (< 4 months), the Ross or Ross-Konno carries incremental hospital risk
Conclusions
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
• Ross operation should be reserved to children without feasible repair options
• Modifications of the root technique (support) and avoidance of the subcoronary technique in children may improve autograft durability
• The Ross or Ross-Konno should be delayed in neonates and infants whenever feasible
• High risk or repeat aortic valve balloon dilation should be discouraged to avoid need for neonatal/infant urgent Ross procedures
• Ross operation should be reserved to children without feasible repair options
• Modifications of the root technique (support) and avoidance of the subcoronary technique in children may improve autograft durability
• The Ross or Ross-Konno should be delayed in neonates and infants whenever feasible
• High risk or repeat aortic valve balloon dilation should be discouraged to avoid need for neonatal/infant urgent Ross procedures
Inferences
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Discussion II
1. Six patients were younger than 3
months
2. Median age at follow-up was 15.6 years
3. Aortic valve/left ventricular outflow
4. tract (LVOT) anomalies were congenital
in 49 (92%)
5. Seventy percent had previous surgery
or balloon valvuloplasty
6. Root replacement was used in all
53 consecutive Ross procedures have been
performed in patients younger than 18 years.
Hazekamp MH, EJCTS 2005Hazekamp MH, EJCTS 2005
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Pasquali SK, JTCVS 2007Pasquali SK, JTCVS 2007
Discussion II
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Pasquali SK, JTCVS 2007Pasquali SK, JTCVS 2007
Discussion II
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
No patient developed significant autograftinsufficiency or required autograft reinterventionduring the follow-up period. Dilatation of theautograft occurred during the first year aftersurgery and stabilized thereafter.
• The Ross procedure performed in 27 infants < 18 m. of age (median age 5.7 months) (indication: all AS).
• Median follow-up was 6.1 years (range 0.2 to 12.9).
Williams IA, Circulation 2005Williams IA, Circulation 2005
Discussion II
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.
Data on neo-aortic valve function and growth after the Ross procedure in children are limited.
• 74 Patients• 74 Patients
• Median age at Ross was 9 years (range 3 days to 34 years).
• At mid-term follow-up after the Rossprocedure, neo-aortic root size increasessignificantly out of proportion to so-matic growth, and neo-AI is progressive.
• Prior VSD repair and aortic valvereplacement were associated with neo-AIand reintervention.
Pasquali SK, JACC 2007Pasquali SK, JACC 2007
Discussion II
XLIII National Congress SICP & SICCHPED, 16-19 October 2013, Padua.
Early And Late Perspectives Of The Ross (Ross/Konno) Operation In Pediatric Population: An Italian Multi-centric Study.