European Heart Journal Advance Access originally published online on July 22, 2008
European Heart Journal 2008 29(17):2180-2181; doi:10.1093/eurheartj/ehn288
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Is the Ross procedure really a Trojan horse?
Department of Cardiovascular Surgery
Charité
Medical University Berlin
Luisenstrasse 13
Berlin 10117
Germany
Tel: +49 30 450 522 092
Fax: +49 30 450 522 921
Department of Cardiovascular Surgery
Charité
Medical University Berlin
Luisenstrasse 13
Berlin 10117
Germany
Email: pascal.dohmen{at}charite.de
We have read the article by Klieverik et al.1 regarding ‘The Ross operation: a Trojan horse’ with great interest. By the choice of this title, the authors suggest that the use of the autologous pulmonary valve can be utterly devastating. It is understood that the Ross procedure is controversial by itself and the title misleading in consideration of the fact that several authors yielded excellent long-term results.2,3
Modern speculations have described that a horse, the Trojan Horse, was used as a battering ram. The description of the use of a horse was transformed into a myth by later oral historians. It has been suggested that the Trojan Horse actually represents an earthquake that occurred between the wars that could have weakened Troy's walls. However, the deity, Poseidon, had a three-fold function as god of the sea, of horses, and earthquakes.
Results from several authors suggest that the Ross procedure even is an effective and safe tool to treat patients suffering from rheumatic fever and not as worse as suggested. Kumar et al.4 by performing the Ross procedure in rheumatic patients (n = 81) showed freedom from autograft dysfunction at 78.4 ± 5.2% after a median follow-up of 109 months. Dividing this entire group by age, young rheumatics (<30 years) showed 65.0 ± 7.8% freedom of re-operation compared with 98.5 ± 1.0% for older rheumatics (P = 0.0002). Recurrent rheumatic fever, however, developed in five patients, partially due to inappropriate post-operative application of penicillin. Da Costa et al.5 published results of 202 patients, including 61% young rheumatics. In this trial, freedom from autograft dysfunction was remarkable 96.4% after 10 years. In both studies, the autograft was implanted using the root replacement technique.
It should be recognized, however, that the originally described technique by Ross was the subcoronary implantation, which was abandoned in favour of the root replacement technique. Sievers et al.6 reported excellent long-term results with the subcoronary technique. These data are in consistence with our own experience of more than 460 Ross procedures performed since 1994.
Finally, it should be mentioned that an alternative for this patient population would be conventional mechanical or bioprosthetic valve replacement. Ruel et al.7 in a recent study on 314 patients showed an actuarial freedom from re-operation after 20 years of only 73.0 ± 4.9% for mechanical valves and stented bioprostheses of 11.4 ± 3.5%. On the other hand, survival rates at 25 years follow-up was better for patients with tissue valves (52.3 ± 4.4 vs. 41.2 ± 5.2%).
Thus, the Ross procedure is certainly not free of re-operation; however, considering the outcome and re-operation in traditional prostheses, the Ross procedure still has the lowest re-operation rates even in this unique patient population shown by the authors.
References
- Klieverik LMA, Takkenberg JJM, Bekkers JA, Roos-Hesselink JW, Witsenburg M, Bogers AJJC. The Ross operation: a Trojan Horse? Eur Heart J (2007) 28:1993–2000.
[Abstract/Free Full Text] - Chambers JC, Somerville J, Stone S, Ross DN. Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series. Circulation (1997) 96:2206–2214.
[Abstract/Free Full Text] - Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Dávila-Román VG. The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg (2004) 78:773–781.
[Abstract/Free Full Text] - Kumar AS, Talwar S, Saxena A, Singh R. Ross procedure in rheumatic aortic valve disease. Eur J Cardiothoracic Surg (2006) 29:156–161.
[Abstract/Free Full Text] - Da Costa FD, Pereira EW, Barboza LE, Haggi Filho H, Collatusso C, Gomes CH, Lopes SA, Sardetto EA, Ferreira AD, da Costa MB, da Costa IA. Ten-year experience with the Ross operation. Arq Bras Cardiol (2006) 87:583–591.[Medline]
- Sievers HH, Hanke T, Stierle U, Bechtel MF, Graf B, Robinson DR, Ross DN. A critical reappraisal of the Ross operation: Renaissance of the subcoronary implantation technique? Circulation (2006) 114:I504–I511.[Web of Science][Medline]
- Ruel M, Chan V, Bédard P, Kulik A, Ressler L, Lam K, Rubens FD, Goldstein W, Hendry PJ, Masters RG, Mesana TG. Very long-term survival implications of heart valve replacement with tissue versus mechanical prostheses in adults <60 years of age. Circulation (2007) 116:I294–I300.[Web of Science][Medline]
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