The Ross procedure offers several advantages over
traditional prosthetic valve replacements in pediatric
patients, including optimal hemodynamics, avoidance
of anticoagulation, and potential for somatic growth.
These characteristics are particularly valuable in
the growing child.[
5,
6] Our study contributes to the
evidence supporting the use of the Ross procedure in
children by presenting a favorable early outcome, low
reoperation rates, and preserved autograft function
during mid-term follow-up.
Our observed early mortality rate (5.5%) is
consistent with previous pediatric series, where rates
have ranged from 0 to 16% depending on age and
risk profile.[7,8] The single mortality in our cohort
occurred in a critically ill infant who underwent
emergency surgery after prior balloon valvuloplasties
and presented with organ dysfunction. These risk
factors are well-documented predictors of poor
outcome.[4,9]
Importantly, there were no cases of late mortality.
Five-year survival was 94%, which aligns with the
outcomes reported in recent systematic reviews and
registry studies in pediatric cohorts.[10]
No autograft dysfunction or reoperation was
observed in our series. This is a noteworthy finding, as prior studies have reported autograft failure rates
of approximately 1% per year.[9] Several factors may
account for our favorable results, including the use
of precise surgical techniques such as interrupted
sutures at the proximal anastomosis to preserve
geometry, avoidance of reinforcement that may
limit growth, and inclusion technique rather than
full root replacement. However, the absence of
autograft-related complications must be interpreted
cautiously, as some patients were followed at external
centers and limited follow-up beyond 10 years
reduces long-term reliability. We acknowledge that
the possibility of unreported dysfunction due to loss
to follow-up remains.
To prevent conduit degeneration, homografts
were preferentially used. Nevertheless, two patients
required conduit replacement due to degeneration-one
with a pulmonary homograft at year seven, and the
other with a porcine pericardial conduit (BioIntegral
Surgical Inc., Mississauga, Canada) at year three. The
early failure of the latter is consistent with literature
describing an inflammatory response and premature
degeneration associated with this material.[11] Our
five-year freedom from reintervention was 90%,
comparable to prior reports of 79 to 90%.[12,13]
Aortic root dilatation or aneurysm formation did
not occur in any of our patients during follow-up. We attribute this to the use of subcoronary
implantation and the natural anatomical integration
of the pulmonary autograft. Reinforcement
techniques, while sometimes effective in adults, are
not routinely used in children due to concerns over
growth limitation.[9,14,15]
Regarding alternative techniques, the Ozaki
procedure has emerged as a promising reconstructive
option in pediatric aortic valve disease. It offers
avoidance of prosthetic materials and preserves
native aortic root dynamics. However, long-term
durability in children remains uncertain, and it lacks
the growth potential offered by the Ross procedure.
Further comparative studies are needed to define its
role.[3,16,17]
Intraoperative care to preserve the first septal
branch during autograft harvest is essential, as
injury may compromise myocardial perfusion. We
emphasize that meticulous dissection was performed
in all cases to prevent such complications.
No patient in this series required extracorporeal
membrane oxygenation support, including the single
early mortality case. Given the late deterioration and
progression to multi-organ failure, extracorporeal
membrane oxygenation was not initiated due to
the poor likelihood of recovery and ongoing septic
complications.
This study had several limitations. It was limited
by a small sample size and single-center retrospective
design. The follow-up period varied significantly
between patients, and longer-term outcomes beyond
10 years were available for only a few patients,
limiting statistical validity for long-term survival
and reoperation estimates. Additionally, the absence
of a comparison group and potential loss to follow-up
in some cases restricts the generalizability of the
findings. Despite these limitations, our results
support the use of the Ross procedure as a favorable
option for pediatric aortic valve replacement when
performed by experienced surgeons.
In conclusion, this study demonstrated that
the Ross procedure can be performed in pediatric
patients with low mortality and morbidity. With
appropriate surgical technique, the autograft can
function well and grow with the patient, minimizing
the need for reoperation. Our findings suggest that
conduit-related reinterventions are manageable and
do not outweigh the significant benefits of using the
patient's own tissue. While vigilance in long-term follow-up remains essential, the perception that the
Ross procedure converts one valve disease into two
may be overly pessimistic in the context of properly
selected and managed pediatric patients.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, references and
fundings, materials: O.N.T.; Design, literature review:
O.N.T., Y.A.; Control/supervision, critical review: Y.A.,
R.E.L.; Data collection and/or processing, analysis and/or
interpretation, writing the article: M.A., O.N.T.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
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