Aortic Valve Replacement in Infants and Children: Is the Ross and Ross-Konno Procedure an Ideal Long-term Treatment?

Objective: The term “left ventricular outflow tract obstructions” (LVOTO) in infants and children often summarizes a complex and heterogenic disease, requiring multilevel operations as well as interventional procedures necessitating aortic valve replacement including correction of LVOTO if other strategies fail.

Methods: From 1996 till 2015 we performed aortic valve replacement (AVR) on 138 patients. Group A consisted of 112 Ross procedures (90 m/22 f, age: 156.5 months (r: 1–299 months) and Group B of 26 Ross-Konno procedures (13 m/13 f, age: 34 months (r: 0.5–246 months). A retrospective analysis of hospital charts and of a MRI study at the end of the follow-up time was performed.

Results: Median follow-up in group A was 128mo (r: 5–238 months), in group B: 120 months (r: 34–180 months). At implantation median autograft size was 21 mm (r: 12–28 mm) (z-score: 1.8; r: −0.5–6.25) in group A and 16 mm (r: 10–24.5 mm) (z-score: 2.6 (r: 1.25–5.71) in group B (p < 0.05). MRI revealed an aortic root size of 44 mm (r: 21–57 mm) (z-score: 5.1 (r: 0.42–8.6) as well as an aortic annulus size of 28 mm (r: 15–48 mm) in group A. In group B median aortic root measured 29 mm (r: 15–44 mm) (z-score: 0.34–7.67), median aortic anulus 22 mm (r: 10–28 mm) (p < 0.05) at the end of the follow-up period. At the same time, left ventricular function (LVEF) in group A was 64% (r: 47–79), and 65% (r: 52–82) in group B. In group A, median aortic insufficiency was 1.2 ± 0.6; in group B: 0.8 ± 1.4 (MRI calculated). In Group A 39%, in group B all patients had been treated interventionally and/or surgically before. The most frequent additional procedure before AVR was aortic coarctation in 10% of group A and in 42% of group B. The aortic valve has been re-operated in group A in 8 patients (7.14%), in group B in 2 patients (7.69%). Overall mortality was 2.2%.

Conclusion: LVOT pathologies requiring AVR in infants, children and young adults can be treated successfully performing a Ross procedure. In a more complex LVOT- obstruction a Ross-Konno procedure is necessary. During follow-up all patients show a comparable growth of the aortic root, low rates of aortic insufficiency and good cardiac function, although Ross-Konno patients are younger and suffer on a more complex disease. Meticulous follow-up including MRI is needed.