EJCTS Click here to go to Edwards website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sampath Kumar, A.
Right arrow Articles by Singh, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Sampath Kumar, A.
Right arrow Articles by Singh, R.
Related Collections
Right arrow Valve disease

Eur J Cardiothorac Surg 2006;29:156-161
© 2006 Elsevier Science NL

Ross procedure in rheumatic aortic valve disease

Arkalgud Sampath Kumar a , * , Sachin Talwar a , Anita Saxena a , Rajvir Singh b

a Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
b Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Received 6 October 2005; received in revised form 15 November 2005; accepted 18 November 2005.

* Corresponding author: Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India. Tel.: +91 11 26588889; fax: +91 11 26588889. (Email: asampath_kumar{at}hotmail.com).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Objective: To assess the results of aortic valve replacement with the pulmonary autograft in patients with rheumatic heart disease. Methods: From October 1993 through September 2003, 81 rheumatic patients with aortic valve disease, mean age 29.5 ± 11.9 years (11–56 years) underwent, the Ross procedure with root replacement technique. Forty patients were 30 years of age or below (young rheumatics). Associated procedures included mitral valve repair (n = 19), open mitral commissurotomy (n = 15), tricuspid valve repair (n = 2), and homograft mitral valve replacement (n = 2). Results: Early mortality was 7.4% (six patients). Mean follow-up was 92.3 ± 40.9 months (7–132 months, median 109 months). Sixty of the 73 patients whose follow-up was available (82%) had no significant aortic regurgitation. Re-operation was required in seven (8.4%) patients for autograft dysfunction with failed mitral valve repair (n = 3), autograft dysfunction alone (n = 2) and failed mitral valve repair alone (n = 2). No re-operations were required for the pulmonary homograft. There were six (7.5%) late deaths. Actuarial survival and re-operation-free survival at 109 months were 84.5 ± 4.1% and 90.5 ± 3.7%, respectively. Freedom from significant aortic stenosis or regurgitation was 78.4 ± 5.2% and event-free survival was 64.6 ± 5.8%. When compared to rheumatics above 30 years of age, the relative risk of autograft dysfunction was high in the young rheumatics. Conclusion: The Ross procedure is not suitable for young patients with rheumatic heart disease. However, it provides acceptable mid-term results in carefully selected older (>30 years) patients with isolated rheumatic aortic valve disease.

Key Words: Ross operation • Rheumatic heart disease • Aortic valve replacement • Autograft


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Aortic valve replacement (AVR) with a prosthetic valve is the most commonly performed operation for patients with rheumatic aortic valve disease. The pulmonary autograft, which was first used by Ross in 1967 [1] for AVR, has the advantages of good hemodynamics, ability to remodel, growth potential, and good long-term results in carefully selected patients [2–8]. We reported our early experience in young patients with rheumatic heart disease (RHD) in 1999 [9]. In this study, we present detailed results obtained in 81 consecutive rheumatic patients.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Between October 1993 and September 2003, 81 patients with rheumatic heart disease underwent AVR with the pulmonary autograft (Ross procedure). Of these, 40 patients were 30 years of age or below (young rheumatics). Fifty-nine patients (72.8%) had dyspnoea as the predominant symptom. Fifty-six (69%) were in NYHA classes III and IV (Table 1 ). Pre-operative trans-thoracic echocardiography was performed in all patients and cardiac catheterization and cine angiography was performed on suspicion of associated mitral valve or coronary artery disease.


View this table:
[in this window]
[in a new window]
  		Table 1. Profile of patients undergoing the Ross procedure
 
Informed consent was obtained from all patients. As a matter of policy, surgery was not performed if there was any clinical or biochemical evidence of acute rheumatic activity. A period of at least 12 weeks of freedom from acute rheumatic activity was ensured prior to surgery.

Intra-operative trans-esophageal echocardiography (TEE) was performed in all the patients. Exclusion criteria for the Ross procedure included (a) aortic root diameter of 30 mm or more, (b) significant left ventricular dysfunction, (c) patients requiring emergency surgery, (d) mitral valve disease requiring prosthetic valve replacement, (e) significant mismatch between the aortic root diameter and the pulmonary valve, and (f) bicuspid pulmonary valve or pulmonary regurgitation. After 1998, we have not performed this procedure in young (under 30 years) rheumatics.

The surgical procedure has been described in detail by us earlier [4]. Root replacement technique with coronary artery implantation was used in all patients. The left coronary artery was not implanted as a button. Instead, the left coronary ostium was left attached to a tongue of the distal aortic wall. Right ventricle–pulmonary artery continuity was restored using an antibiotic-preserved (n = 36) or cryo-preserved (n = 45) pulmonary (n = 79) or aortic (n = 2) homograft obtained from our own tissue valve bank. Associated procedures, post-operative results, and follow-up data are presented in Table 2 . The techniques of associated procedures have been described by us earlier [10]. For isolated Ross procedure, the mean aortic cross clamp and cardiopulmonary bypass times were 116.4 ± 11.4 min (range 87–189 min) and 157 ± 23.2 min (range 124–217 min), respectively. When mitral valve procedure was done concomitantly, these increased to 135 ± 31 min (range 109–230 min) and 168 ± 32 min (range 140–280 min), respectively.


View this table:
[in this window]
[in a new window]
  		Table 2. Operative data, post-operative results, and follow-up of patients undergoing the Ross procedure
 
After weaning from cardiopulmonary bypass, TEE was performed in all patients to assess autograft function and associated procedures. Prior to discharge from the hospital, trans-thoracic echocardiography was performed in all patients and this was repeated at 6-monthly intervals. Aortic regurgitation (AR) was assessed on a scale of +1 to +4 according to published criteria [11]. AR of grade +1 was considered mild. Peak gradients less than 25 mmHg across the aortic valve were considered as mild aortic stenosis (AS) and those ≥50 mmHg were considered as significant AS.

No anticoagulants or anti-platelet drugs were prescribed. Long-acting benzathine penicillin 3 weekly was prescribed to all patients below 45 years of age. All patients received itraconazole for 6 weeks following surgery as prophylaxis against fungal endocarditis.

2.1 Statistical analysis
This was performed with SPSS for windows 10.0 software package (SPSS Inc., Chicago, IL, USA). Mean, median, and standard deviation have been calculated for continuous variables. Freedom from valve-related events and actuarial estimates were calculated using the Kaplan–Meier analysis. The estimates were compared with the Mantel–Cox (log-rank) test. A valve-related event was defined as any episode of thromboembolism, hemorrhage, congestive heart failure, infective endocarditis, structural deterioration, or significant gradients as per published criteria [12]. Linearized rates for these events are reported. Cox's proportional hazard model was used to analyze factors associated with a higher early and late mortality and the development of autograft dysfunction.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusion
 Appendix A
 References
 
3.1 Hospital mortality
All patients survived the operation. There were six (7.4%) early deaths due to bleeding (n = 2), malignant ventricular arrhythmias (n = 2), and persistent low cardiac output (n = 2).

3.2 Early re-operation
Two patients underwent re-operation for excessive mediastinal bleeding. In one patient, the bleeding was from the raw surface of the posterior wall of the right ventricular outflow tract. In the other patient, the source of bleeding was unrelated to the suture lines.

3.3 Early autograft function
Intra-operative TEE revealed satisfactory autograft function with trivial or no aortic regurgitation in all the patients. Three patients below 30 years of age had mild mitral regurgitation (MR).

3.4 Follow-up
All survivors were seen in the outpatient clinic at 6-monthly intervals and they underwent clinical examination and echocardiography. Between July 2004 and December 2004, the records of 73 of the 75 survivors (97.3%) were obtained, and their last follow-up during this period was taken for statistical analysis. Overall mean follow-up was 92.3 ± 40.9 months for both groups (7–132 months, median 109 months) and total 561.5 years. In patients below 30 years, the follow-up was 7–132 months (mean 100 ± 3.5 months), whereas in patients above 30 years, it was 8–132 months (mean 84.1 ± 42.4 months). However, the results are reported at an overall median follow-up of 109 months. Among survivors, 15 (20%) were followed up for 10 or more years, 62 (82.7%) for 7 or more years, 67 (89.3%) for more than 5 years, 70 (9.3%) for more than 3 years, and 73 (100%) for more than 6 months.

There were no thromboembolic complications in the survivors. Three patients had significant hemolysis (0.5 events per 100 patient-years). In the first two patients, it was associated with excessive mediastinal bleeding, disseminated intravascular coagulation and early death. In the third patient, it was associated with mild mitral regurgitation which subsided gradually.

One 18-year-old patient developed bacterial endocarditis 9 months following initial operation and died.

3.5 Recurrent rheumatic fever
Two young rheumatics, aged 11 and 13 years (patient no. 3 of Table 3 ), who had undergone the Ross procedure and mitral valve repair, developed acute rheumatic activity and CHF requiring hospitalization after 8 and 12 months, respectively. In these patients, there was no polyarthritis, but the erythrocyte sedimentation rate (ESR) and antistreptolysin titers (ASLO) had risen significantly. Both these patients developed severe AR and moderate-to-severe MR. The first patient had not complied with post-operative penicillin prophylaxis, whereas the second patient was regularly taking it. Both patients were adequately decongested and advised re-operation; the first patient, however, died 6 months later and the second one underwent re-operation.


View this table:
[in this window]
[in a new window]
  		Table 3. Re-operations following the Ross procedure
 
Patient nos. 1 and 4 of Table 3 had recurrent history of fever and joint pains starting 12 and 24 months, respectively, following initial operation, but there was no laboratory evidence supporting rheumatic activity. Both these patients had stopped regular penicillin prophylaxis. At re-operation, however, the autograft showed features of rheumatic valvulitis. Besides this, two other patients aged 14 and 17 years (Patient no. 2 of Table 3) and on regular penicillin prophylaxis had a similar history without laboratory evidence of rheumatic activity.

There was no clinical or laboratory evidence of recurrent rheumatic activity in the remaining patients.

3.6 Late autograft function
Out of the 73 survivors, whose follow-up was available, 60 (82%) had no significant AR. Fifteen patients had significant aortic regurgitation (2.67 events per 100 patient-years) which was moderate in 11 patients and severe in another four patients. These patients developed significant AR 57.6 ± 36.2 months after the operation; six of these patients had evidence of recurrent attacks of rheumatic fever and developed significant AR within 2 years of operation. The occurrence of rheumatic process in these patients is detailed above. In other nine patients, there was no clinical or laboratory evidence of recurrent rheumatic activity.

On multivariate analysis, the probability of development of AR was higher in young (<30 years) rheumatics (hazard ratio 62.5, 95% CI = 0.94–100, p = 0.053). All four patients with severe AR underwent re-operation; two of these required double valve replacement for failure of associated mitral valve repair. In all these patients, prosthetic valves were implanted. Out of the 11 patients with moderate AR, one underwent double valve replacement with a prosthetic valve 48 months after the initial operation for failed mitral repair in addition to the AR; two patients died of CHF 24 and 5 months, respectively, after the initial operation; one of bacterial pneumonia 2 months after operation and the remaining seven patients with moderate AR continue to be in NYHA class I and are being closely followed-up. At the median follow-up of 109 months, freedom from autograft dysfunction was 78.4 ± 5.2% (95% CI, 68–88.8) for the entire group; in young rheumatics, it was 65 ± 7.8% (95% CI, 49.4–80.6) as compared to 98.5 ± 1% (95% CI, 96.5–100) in older rheumatics group (log-rank = 13.83, p = 0.0002) (Fig. 1 ).


Figure 1
View larger version (17K):
[in this window]
[in a new window]
  		Fig. 1. Freedom from aortic regurgitation (Kaplan–Meier) in patients with rheumatic heart disease undergoing the Ross procedure.

 
3.7 Fate of right ventricular outflow tract
Two patients had pulmonary homograft dysfunction (0.3 events per 100 patient-years). One patient has a gradient of 48 mmHg or more across the right ventricular outflow tract at 7 years of follow-up. The other patient has moderate pulmonary regurgitation. However, these patients are asymptomatic and are being followed up.

3.8 Late re-operation (Table 3)
Late re-operation was required in seven patients (1.2 events per 100 patient-years) after a mean period of 47.5 ± 38.9 months (range 12–108 months, median 48 months). Two patients underwent re-operation for failed mitral valve repair with normal pulmonary autograft function. The first of these two patients underwent mitral valve replacement with a mitral homograft 26 months after the initial operation. However, she died 3 months later due to persistent congestive cardiac failure. The other patient underwent prosthetic mitral valve replacement 31 months after initial operation. Three patients required prosthetic double valve replacement for autograft failure with failure of associated mitral valve repair 12 and 48 months (two patients) following initial operation. Two patients with severe aortic regurgitation underwent aortic valve replacement with a mechanical prosthesis 56 and 108 months after initial operation. At re-operation, mechanical valves were implanted because of patients’ choice.

At re-operation, patient nos. 1 and 4 of Table 3 were found to have significant autograft dilatation due to recurrent attacks of rheumatic activity. In the other patient, the geometry of the aortic sinuses was maintained, but the autograft cusps showed thickening, retraction, and failure of co-aptation without any prolapse or commissural fusion. On histological examination, there was valve thickening, fibrosis, and active chronic inflammation with small vessel and intimal proliferation as detailed in our prior publication [9].

At the median follow-up of 109 months, freedom from re-operation was 90.5 ± 3.7% (95% CI, 83.1–98.21) for the entire group; in young rheumatics, it was 83 ± 6.3% (95% CI, 70.4–95.6) as compared to 96.9 ± 3.1% (95% CI, 90.7–100) in older rheumatics (log-rank = 2.87, p = 0.09) (Fig. 2 ).


Figure 2
View larger version (18K):
[in this window]
[in a new window]
  		Fig. 2. Re-operation-free survival (Kaplan–Meier) in patients with rheumatic heart disease undergoing the Ross procedure.

 
3.9 Late deaths and survival
There were six late deaths (1 event per 100 patient-years). These were due to mitral homograft failure (n = 2), persistent CHF due to autograft failure (n = 2), bacterial pneumonia (n = 1), and bacterial endocarditis (n = 1). One patient who underwent mitral valve replacement with a homograft died 6 months later due to the mitral homograft failure. Another patient had a mitral homograft replacement following failed mitral valve repair and died 2 months later due to mitral homograft failure. Two patients with autograft failure died of persistent congestive heart failure 24 and 5 months, respectively, after the operation. The patients with bacterial pneumonia and infective endocarditis died 2 and 9 months, respectively, after initial surgery.

At 109 months, the actuarial survival was 84.5 ± 4.1% (95% CI, 76.3–92.7) for the entire group; in young rheumatics, it was 84.9 ± 5.7% (95% CI, 73.5–96.3) compared to 84.5 ± 5.8% (95% CI, 72.9–96.1) in older rheumatics (log-rank = 0.05, p = 0.82) (Fig. 3 ).


Figure 3
View larger version (18K):
[in this window]
[in a new window]
  		Fig. 3. Actuarial survival (Kaplan–Meier) in patients with rheumatic heart disease undergoing the Ross procedure.

 
Event-free survival at 109 months was 64.6 ± 5.8% (95% CI, 53–76.2) for the entire group; in young rheumatics it was 51.6 ± 8% (95% CI, 43.6–59.6) compared to 81.9 ± 6.2% (95% CI, 69.5–94.3) in older rheumatics (log-rank = 5.21, p = 0.022) (Fig. 4 ).


Figure 4
View larger version (18K):
[in this window]
[in a new window]
  		Fig. 4. Event-free survival (Kaplan–Meier) in patients with rheumatic heart disease undergoing the Ross procedure.

 
There were no specific predictors of early or late death on multivariate analysis.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusion
 Appendix A
 References
 
The pulmonary valve has been shown to be a near ideal substitute for the disease aortic valve [2–8]. Realizing this, we were very enthusiastic in its use for AVR in patients of all aortic valve pathologies. In our early experience, most of the patients had RHD and were 30 years of age or below. Thirty-four of these patients had associated mitral valve disease amenable to repair. In these patients, we thought that the pulmonary autograft would be a good option once the mitral repair was satisfactory as it would offer to these young patients good hemodynamics, freedom from anticoagulation and thromboembolism, growth potential and ability to remodel, and relative resistance to infection as compared to prosthetic heart valves [3–7]. However, we were disappointed with the results. More than one-third of the young rheumatics (15 out of 36 followed up) developed significant autograft dysfunction within 5 years of surgery, six of them developed significant AR within 2 years and a majority of them required re-operation for autograft dysfunction or failed mitral valve repair.

The reason for involvement of the pulmonary autograft in rheumatic disease process has been widely debated [9,13–16]. Why it occurs in patients with recurrent rheumatic activity is unknown. Cessation of penicillin prophylaxis may not be the only reason for this as it has been shown that higher infection rates in overcrowded areas may render penicillin prophylaxis ineffective [17,18]. The lack of a definite history of carditis or recurrent joint pains does not entirely rule out disease recrudescence as a positive history is not always forthcoming [17]. In fact, only 6 of the 15 patients with significant AR in our study had some clinical or laboratory evidence of rheumatic fever, and only three of these patients had stopped penicillin prophylaxis but all patients undergoing re-operation demonstrated features of rheumatic valvulitis in the autograft.

Even despite recurrent rheumatic fever, involvement of the pulmonary valve in the rheumatic disease process is rare [19], and we have observed only two patients with quadrivalvular rheumatic heart disease in the last 20 years in whom there was clear evidence of pulmonary valve involvement [20]. The pulmonary autograft cusps looked perfectly normal at the first operation although at the microscopic level, their involvement in the rheumatic process cannot be ruled out entirely. But surprisingly, at re-operation, the intra-operative TEE findings were indistinguishable from those due to rheumatic aortic valve disease and at operation the cusps were thickened and retracted, and their histological examination showed changes typical of rheumatic valvulitis. We do not know why a valve which is relatively free from chronic rheumatic valvulitis should develop these changes when it is transplanted into the aortic position. The pulmonary autograft is now an aortic valve, and mechanical forces in the aortic position may make it susceptible to rheumatic involvement as this [9], but this is debatable.

We did not observe these findings in older rheumatics and those without associated mitral valve disease. The reasons are not clear, but this is probably related to the natural history of the disease in which the attacks of rheumatic fever become infrequent with advancing age. The results in older rheumatics have been far more satisfactory, and this has encouraged us to continue to perform this procedure in rheumatics older than 30 years of age without mitral valve disease.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
Appendix A
 References
 
The pulmonary autograft is not an ideal valve substitute in young rheumatics and carries a high failure rate. However, it provides satisfactory results in carefully selected older patients with isolated rheumatic aortic valve disease.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
References
 
Conference discussion

Dr R. Lorusso (Brescia, Italy): Could you have the chance to evaluate histologically the explanted valve, I mean, the pulmonary valve you explanted, especially in the very young patients? And do you think that your results could be due to a very active rheumatic disease which involved also the pulmonary valve?

Dr Kumar : Yes, we did histological examination and we found characteristic features of rheumatic valvulitis in the autograft in the explanted valves. I have not shown the histopathological slides because of time, but that is our observation.

Dr Z. Al-Halees (Riyadh, Saudi Arabia): We also have a large population of rheumatic patients that underwent the Ross procedure and so far we have accumulated more than 400 patients who underwent the Ross procedure, more than 60% of them have rheumatic etiology.

We basically came to almost the same conclusions. We looked at the failures in the rheumatics in particular, and the two strong predictors of failure were the presence of pure aortic valve regurgitation and dilated aortic roots.

In our analysis, we actually found that patients who have roots that are more than 27–28 mm are at much higher risk than those with smaller roots. And this was the case irrespective of the age of the patient. Since that time we have limited our Ross procedure in the rheumatics with aortic valve regurgitation to smaller roots. That seemed to have improved the results.

Another strong predictor of failure was the presence of concomitant severe rheumatic mitral valve regurgitation. So if you exclude those patients from the Ross, the ones with dilated aortic roots and those with concomitant rheumatic mitral valve regurgitation, I believe the outcome is going to be a little bit better than what you reported.

Dr Kumar : As a rule, we do not do Ross procedures for patients who have an aortic annulus diameter of more than 30 mm, or if they have a discrepancy in the aortic and pulmonary diameters of more than 5 mm. So we have not done this operation in patients with large aortic roots. And in India, we find that these patients who come with rheumatic aortic valve disease have relatively smaller roots.

And I agree with you, the second point which you raised about mitral valve disease, it's unfortunate our enthusiasm to give these patients a much better life without anticoagulants actually backfired. And we do not any longer do Ross procedures for patients with associated mitral valve disease.

Dr Al-Halees : My question is, in our experience, we found that patients with predominant aortic stenosis, even if they’re rheumatic, they still behave well. Is that your experience as well?

Dr Kumar : Yes.

Dr Y. Yalcinbas (Istanbul, Turkey): Can you comment on the high incidence of endocarditis in your series. Was it related to the homograft or the autograft?

Dr Kumar : This problem of endocarditis was in the beginning of our experience and that was probably due to the homograft valve. And subsequently, we changed the air conditioning in our operating theaters and we got rid of this problem even in the homograft aortic valve replacement patients as well as in the Ross procedure.

Dr T. Chotivatanapong (Nonthaburi, Thailand): May I ask you about the post-operative blood pressure control in relation to the degree of aortic regurgitation post-operatively, since there is same relationship between these.

Dr Kumar : None of these patients had hypertension. They were all normotensive and we did not have any problem with hypertension in this group of patients.

Dr E. Akl (Cairo, Egypt): What's your valve of choice for young patients below the age of 20 with repairable mitral valve or just isolated aortic regurgitation?

Dr Kumar : We have recently published our results with the aortic valve repair and mitral valve repair as well. Yesterday I presented our results with the mitral valve repair.

Our first choice of operation for these patients is an attempt at repair. We’ll repair the mitral valve and even attempt repair of the aortic valve. If it is not possible, and if only mitral valve can be repaired, we still use a mechanical valve for the aortic valve if it requires replacement.


   Footnotes
 
{star} Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 

  1. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 1967;2:956-958.[Medline]
  2. Ross D, Jackson M, Davies J. The pulmonary autograft—a permanent aortic valve. Eur J Cardiothorac Surg 1992;6:113-116.[Abstract]
  3. Gatzoulis MA. Ross procedure: the treatment of choice for aortic valve disease?. Int J Cardiol 1999;71:205-206.[Medline]
  4. Choudhary SK, Govil A, Kumar AS. Ross procedure: aortic valve replacement with pulmonary autograft. Indian J Thorac Cardiovasc Surg 2001;17:243-257.
  5. 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]
  6. Elkins RC. The Ross operation: a 12-year experience. Ann Thorac Surg 1999;68(3 Suppl.):S14-S18.[Medline]
  7. Oswalt JD, Dewan SJ, Mueller MC, Nelson S. Highlights of a ten-year experience with the Ross procedure. Ann Thorac Surg 2001;71(5 Suppl.):S332-S335.[Medline]
  8. Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Davila-Roman VG. The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg 2004;78:773-781.[Abstract/Free Full Text]
  9. Choudhary SK, Mathur A, Sharma R, Saxena A, Chopra P, Roy R, Kumar AS. Pulmonary autograft: should it be used in young patients with rheumatic disease?. J Thorac Cardiovasc Surg 1999;118:483-490.[Abstract/Free Full Text]
  10. Choudhary SK, Talwar S, Dubey B, Chopra A, Saxena A, Kumar AS. Mitral valve repair in a predominantly rheumatic population. Long-term results. Tex Heart Inst J 2001;28:8-15.[Medline]
  11. Perry GJ, Hemeke F, Nanda MC, Byard C, Soto B. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol 1987;9:952-959.[Abstract]
  12. Edmunds LH, Clark RE, Cohn LH, Grunkemeier GL, Miller DC, Weisel RD. Guidelines for reporting morbidity and mortality after cardiac valvular operations. J Thorac Cardiovasc Surg 1996;112:708-711.[Free Full Text]
  13. DeVries H, Bogers AJJC, Schoof PH, Mochtar B, Spitaela SE, Perlroth MG, Hess J, Bos E. Pulmonary autograft failure caused by a relapse of rheumatic fever. Ann Thorac Surg 1994;57:750-751.[Medline]
  14. Kumar N, Prabhakar G, Gometza B, Al-Halees Z, Duran CM. The Ross procedure in the young rheumatic population: early clinical and echocardiographic profile. J Heart Valve Dis 1993;2:376-379.[Medline]
  15. Al-Halees Z, Kumar N, Gallo R, Gometza B, Duran CMG. Pulmonary autograft for aortic valve replacement in rheumatic disease: a caveat. Ann Thorac Surg 1995;60:S172-S176.[Medline]
  16. Pieters FA, Al-Halees ZA, Hatle L, Sahid MS, Al-Amri M. Results of the Ross operation in rheumatic versus non-rheumatic aortic valve disease. J Heart Valve Dis 2000;9:38-44.[Medline]
  17. Padmawati S. Epidemiology of cardiovascular disease in India. Circulation 1962;25:703-710.[Free Full Text]
  18. Strasser T, Rotta J. The control of rheumatic fever and rheumatic heart disease. WHO Chronicle 1973;27:49.[Medline]
  19. Espino-Vela J, Conteras R, Rustrian-Sosa F. Rheumatic pulmonary valve disease. Am J Cardiol 1969;23:12-18.[Medline]
  20. Talwar S, Jayanthkumar HV, Sharma G, Kumar AS. Quadrivalvular rheumatic heart disease. Int J Cardiol 2006;106:117-118.[Medline]



This article has been cited by other articles:


Home page
 CirculationHome page
J. J.M. Takkenberg, L. M.A. Klieverik, P. H. Schoof, R.-J. van Suylen, L. A. van Herwerden, P. E. Zondervan, J. W. Roos-Hesselink, M. J.C. Eijkemans, M. H. Yacoub, and A. J.J.C. Bogers
The Ross Procedure: A Systematic Review and Meta-Analysis
Circulation, January 20, 2009; 119(2): 222 - 228.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
P. M. Dohmen and W. Konertz
Is the Ross procedure really a Trojan horse?
Eur. Heart J., September 1, 2008; 29(17): 2180 - 2181.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
S. Kabbani, H. Jamil, F. Nabhani, A. Hamoud, K. Katan, N. Sabbagh, A. Koudsi, L. Kabbani, and G. Hamed
Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations.
J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 902 - 908.e7.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sampath Kumar, A.
Right arrow Articles by Singh, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Sampath Kumar, A.
Right arrow Articles by Singh, R.
Related Collections
Right arrow Valve disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS