Commentary: Phenotype versus physiology—what’s at the root of Ross dysfunction?

Central MessagePediatric patients with preoperative aortic insufficiency have worse long-term autograft durability after the Ross procedure compared with children with aortic stenosis or mixed disease.See Article page XXX. Pediatric patients with preoperative aortic insufficiency have worse long-term autograft durability after the Ross procedure compared with children with aortic stenosis or mixed disease. See Article page XXX. In this month’s edition of the Journal, Bouhout and colleagues1Bouhout I. Singh S. Nguyen S. Vinogradsky A. Barrett C. Kalfa D. et al.Impact of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure.J Thorac Cardiovasc Surg. 2023; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (1) Google Scholar report their 27-year experience studying 125 patients undergoing the Ross procedure to determine the impact of preoperative aortic insufficiency (AI) on long-term autograft durability. They found that patients with preoperative AI versus aortic stenosis (AS) or mixed AS/AI had a significantly greater rate of autograft dysfunction compared with patients with preoperative AS or mixed disease (39% vs 13%). By echocardiography, the sinuses of Valsalva dilated at similar rates between the 2 cohorts, but annular dilation occurred at a much faster rate in the AI cohort. Importantly, this study not only reinforces the effect of preoperative aortic valve pathology on long-term outcomes in children undergoing the Ross procedure, but it also forces us to critically evaluate the way in which we preoperatively evaluate, make a surgical recommendation, and counsel our patients. One of the major themes of this study is the effect of phenotype versus physiology on the aortic root in children. The authors dichotomized their cohort based on the primary aortic valve pathology before any surgical or catheter-based intervention. For instance, a neonate who presents with severe AS and undergoes a balloon valvuloplasty would be assigned to the AS cohort even if they develop severe AI and over the next decade developed a dilated annulus before presenting for aortic valve replacement. The inherent assumption is that phenotype is more impactful than years of physiology, and perhaps there is something phenotypically dysfunctional in patients with AI that predisposes them to dilation. And Although this argument is valid, the question cannot fully be answered in this study. It is important to consider the possibility that if patient cohort identification was predicated on pre-Ross physiology rather than preintervention phenotype that the results may vary. A second theme is the impact of autograft support and stabilization in pediatric patients undergoing the Ross. In this study 11 patients received some type of an annular stabilization procedure, and none of them have developed autograft dysfunction to date. The authors now stabilize an annulus starting at 18 mm and downsize an annulus over 25 mm using a variety of techniques. In addition, although the authors reported similar amounts of sinotubular junction (STJ) enlargement over time between cohorts, optimal size necessitating STJ stabilization and method (aortoplasty, interposition graft) also remain unanswered. It is critical that we better determine optimal size and surgical methods for annular and STJ stabilization without negatively impacting somatic growth or long-term hemodynamics in children. What then is the optimal strategy for a 4-year-old patient with an ascending aorta measuring 22 mm with severe AI but an annulus of only 14 mm? Although many questions remain about optimal timing and strategy to prolong autograft durability in children, we must remain very intentional about choosing the right patient to ensure the right outcomes. With the current explosion of (re)interest in the Ross, we need to ensure that we don’t falsely nullify the benefits of a terrific operation by employing it incorrectly in the wrong patients. The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedureThe Journal of Thoracic and Cardiovascular SurgeryPreviewPrimary aortic insufficiency (AI) is a risk factor for autograft reintervention in adults undergoing the Ross procedure. We sought to examine the influence of preoperative AI on autograft durability in children and adolescents. Full-Text PDF