What is the post-operative management of a patient who underwent the Ross procedure?

Post-Operative Management of Patients Who Underwent Ross Procedure

Patients who have undergone the Ross procedure require regular, lifelong cardiology follow-up with specific monitoring of both the autograft and pulmonary homograft function to ensure optimal outcomes and early detection of complications. 1

Initial Post-Operative Assessment (First 6-12 Weeks)

Timing of First Follow-up Visit

• First post-operative visit should occur within 6 weeks of discharge if no inpatient rehabilitation was completed
• If rehabilitation was completed, first visit should be within 12 weeks 1

Components of Initial Assessment

• Wound healing evaluation
• Baseline clinical assessment:
  • Symptom status (dyspnea, chest pain, palpitations)
  • Physical examination with focus on cardiac auscultation
  • Heart rhythm and ECG abnormalities
  • Chest X-ray to ensure resolution of post-operative abnormalities
  • Echocardiography to assess:
    • Pericardial effusion
    • Ventricular function
    • Autograft function
    • Pulmonary homograft function
  • Laboratory tests including hematology, biochemistry, and tests for hemolysis 1

Long-Term Follow-up Protocol

Frequency of Follow-up

• All patients should receive lifelong cardiology follow-up at a cardiac center 1
• Yearly follow-up is recommended for patients who have undergone the Ross procedure 1

Monitoring Parameters

1. Autograft (Neo-aortic valve) Assessment:

   • Monitor for autograft dilatation
   • Assess for progressive aortic regurgitation
   • Risk of autograft reintervention is approximately 0.69% per patient-year 2
   • Preoperative aortic regurgitation and larger aortic annulus diameter are independent predictors for autograft reintervention 2, 3

2. Pulmonary Homograft Assessment:

   • Monitor for right-sided pulmonary homograft obstruction and/or regurgitation
   • Risk of right ventricular outflow tract reintervention is approximately 0.62% per patient-year 2
   • Use of biological valve and younger patient age are independent predictors for RVOT reintervention 2

3. Coronary Artery Function:

   • Monitor for signs of myocardial ischemia due to potential proximal coronary obstruction or kinking 1

4. Imaging Studies:

   • Echocardiography at each follow-up visit to assess:
     • Autograft function and dimensions
     • Pulmonary homograft function
     • Ventricular size and function 1
   • Additional imaging (TEE, MRI) as indicated by symptoms or TTE findings

Specific Complications to Monitor

Valve-Related Complications

• Autograft failure: Occurs at a rate of approximately 0.69% per patient-year 2
• Pulmonary homograft failure: Occurs at a rate of approximately 0.62% per patient-year 2
• Endocarditis: Incidence of approximately 0.36% per patient-year 2
• Valve thrombosis: Rare but possible, incidence of approximately 0.07% per patient-year 2
• Major bleeding: Incidence of approximately 0.15% per patient-year 2
• Stroke: Incidence of approximately 0.13% per patient-year 2

Reintervention Risk

• Freedom from any reintervention at 25 years is approximately 71.1% 4
• Freedom from autograft reintervention at 25 years is approximately 80.3% 4
• Freedom from homograft reintervention at 25 years is approximately 86.3% 4
• Perioperative mortality for Ross-related reinterventions is low (0-3.8%) 4, 5

Endocarditis Prophylaxis

• Endocarditis prophylaxis is recommended in all cases 1

Physical Activity and Sports Recommendations

• High-level activity is possible in uncomplicated cases with good LV function 1
• Contact sports are contraindicated in patients on anticoagulants 1

Pregnancy Considerations

• Anticoagulants may cause embryopathy if mechanical valves are used in reoperations 1
• Women with BAV and ascending aorta diameter >4.5 cm should be counseled about high risks of pregnancy 1

Long-Term Outcomes

• The Ross procedure provides excellent long-term survival comparable to the general population 2, 4, 3
• 25-year survival rate is approximately 75.8-83.0% 2, 4
• Freedom from valve-related deaths at 16 years is approximately 96.8% 3

Conclusion

The Ross procedure offers excellent long-term outcomes with survival rates comparable to the general population. While there is a risk of reoperation over time, the incidence of other valve-related complications is very low. Careful and regular monitoring of both the autograft and pulmonary homograft function is essential to detect early signs of deterioration and plan timely interventions if needed.