BACKGROUND: Aortic valve damage is the most common valvular heart disease in developed countries. The Ross procedure is an alternative to the aortic valve replacement with a prosthesis, providing a longer survival without reoperation and without the need for anticoagulation therapy. The unavailability of homografts for the pulmonary valve replacement is one of the limiting factors for a more common utilization of this therapeutic method. CASE SUMMARY: This case report presents a 35-year-old Caucasian male with a bicuspid aortic valve and severe aortic regurgitation. The patient underwent the Ross procedure with the stabilization of the aortic ring and sinotubular junction. A tubular prosthesis was created from the bovine pericardium, into which three neo-cusp valves were fashioned from autologous pericardium. The new pulmonary conduit was sutured distally to the distal pulmonary trunk and proximally to the right ventricular outflow tract. Four months post-operatively, the follow-up echocardiographic examination documented that the valve in the aortic position had no regurgitation, a maximum velocity of 1.25 m/s, and a peak gradient of 6.25 mmHg. The valve in the pulmonary position showed a trace regurgitation and mean pressure gradient of 13 mmHg. DISCUSSION: The combination of the modified Ross procedure with neo-cuspidalization according to Ozaki for a new pulmonary valve thus offers hope for an extended survival without reoperation in paediatric and non-elderly adult patients with an aortic valve dysfunction. This technique is additionally applicable by cardiac surgery centres without access to pulmonary homografts.

• Keywords
• Aortic valve stenosis and regurgitation, Case report, Ozaki procedure, Ross procedure,
• Publication type
• Journal Article MeSH
• Case Reports MeSH

BACKGROUND: The optimal treatment of patients with severe symptomatic aortic regurgitation (AR) is state-of-the-art surgery. Asymptomatic patients with advanced left ventricular (LV) dilatation and/or impaired ejection fraction should undergo surgical treatment, but there is no guidelines consensus on cut-off values for this recommendation. Multimodality imaging has brought new tools for the accurate selection of asymptomatic patients at risk of early clinical deterioration, however, prospective and randomized data are pending. Cardiac magnetic resonance (CMR)-derived AR quantification along with LV remodeling assessment appears to be the most accurate tool for a selection of such patients at risk. TRIAL DESIGN: The objective of our prospective and multicenter study is to determine whether patients at risk of early clinical deterioration as per CMR assessment will benefit from early surgical treatment. The study is designed as a superiority trial to demonstrate that early surgical treatment is safe and more effective than the standard treatment. A total of 217 asymptomatic patients with severe AR, but without current guidelines-based surgical indication, will be enrolled across all centers. We expect 24 % of patients identified as high clinical risk and therefore eligible for 1:1 randomization to early surgical treatment within 3 months or a watchful waiting strategy. Follow-up will be annual. We expect a complete restoration of LV size and function along with improved quality of life and physical performance in a short-term follow-up of 12 months. The primary endpoint will be a composite safety and efficacy with all criteria mandatory: 15 % or larger reduction of baseline CMR-derived LV end-diastolic volume index, LV ejection fraction >50 %, and no major adverse cardiovascular events. The annual follow-up will continue for a minimum of 4 years until the required number of endpoints is achieved to show a statistically significant difference in cardiovascular morbidity and mortality in early surgically treated patients. CONCLUSION: The ELEANOR trial is the first multicenter randomized controlled study to compare early surgical treatment with a watchful waiting strategy in asymptomatic patients with chronic severe AR at high risk of early clinical deterioration as per CMR assessment but without guidelines-based indications for surgical treatment.

• Keywords
• Aortic regurgitation, Asymptomatic, Early surgery, Magnetic resonance, Randomization,
• Publication type
• Journal Article MeSH

BACKGROUND: Unicuspid aortic valve (UAV) is the second most common underlying cause of aortic valve dysfunction in young adults after the bicuspid valve. The valve may be replaced (for example by pulmonary autograft) or repaired using the bicuspidization technique. The aim of our study was to compare short- and mid-term outcomes of Ross procedure with bicuspidization in patients with severe UAV dysfunction. METHODS: This was a multi-center retrospective observational cohort study comparing data from two dedicated Ross centers in the Czech Republic with bicuspidization outcomes provided by AVIATOR registry. As for the Ross group, only the patients with UAV were included. Primary endpoint was mid-term freedom from reintervention. Secondary endpoints were mid-term freedom from major adverse events, endocarditis and pacemaker implantation. RESULTS: Throughout the study period, 114 patients underwent the Ross procedure (years 2009-2020) and 126 patients underwent bicuspidization (years 2006-2019). The bicuspidization group was significantly younger and presented with a higher degree of dyspnea, a lower degree of aortic valve stenosis and more often with pure regurgitation. The primary endpoint occurred more frequently in the bicuspidization group than in the Ross group - 77.9 vs. 97.9 % at 5 years and 68.4 vs. 75.2 % at 10 years (p < 0.001). There was no difference in secondary endpoints. CONCLUSION: Ross procedure might offer a significantly lower mid-term risk of reintervention than bicuspidization in patients with UAV. Both procedures have comparable survival and risk of other short- and mid-term complications postoperatively.

• Keywords
• Ross procedure, aortic valve reconstruction 2, bicuspidization, reintervention, unicuspid aortic valve,
• Publication type
• Journal Article MeSH