Valve-sparing reoperations for failed pulmonary autografts

Central MessageIncreasing evidence supports the safety and efficacy of preserving the pulmonary autograft valve after Ross failure, but durability varies substantially with the mode of valve failure.See Commentary on page XXX. Increasing evidence supports the safety and efficacy of preserving the pulmonary autograft valve after Ross failure, but durability varies substantially with the mode of valve failure. See Commentary on page XXX. Aortic valve replacement is the most common valve operation performed in the United States. Options for replacement include mechanical valves, bioprosthetic valves and, less commonly, aortic valve xenografts, aortic valve homografts, and pulmonary autografts. Each substitute has associated risks and benefits. Bioprostheses are associated with a greater risk of reoperation than mechanical valves because of structural valve deterioration, but mechanical valves typically necessitate lifelong anticoagulation, which increases the risk of hemorrhage and thromboembolism.1Goldstone A.B. Chiu P. Baiocchi M. Lingala B. Patrick W.L. Fischbein M.P. et al.Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.N Engl J Med. 2017; 377: 1847-1857Crossref PubMed Scopus (203) Google Scholar As a result of these associated risks, older patients often opt for bioprostheses whereas younger patients opt for mechanical prostheses. However, reports of improved durability and the initial success of transcatheter aortic valve-in-valve replacement has led to implantation of surgical bioprostheses in younger and younger individuals.1Goldstone A.B. Chiu P. Baiocchi M. Lingala B. Patrick W.L. Fischbein M.P. et al.Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.N Engl J Med. 2017; 377: 1847-1857Crossref PubMed Scopus (203) Google Scholar Surgeons may also replace diseased aortic valves with a living-valve substitute through the Ross procedure.2Ross D.N. Replacement of aortic and mitral valves with a pulmonary autograft.Lancet. 1967; 2: 956-958Abstract PubMed Google Scholar That living substitute, the pulmonary autograft, offers excellent hemodynamics and avoids the therapeutic anticoagulation needed for mechanical prostheses.3Mazine A. El-Hamamsy I. Verma S. Peterson M.D. Bonow R.O. Yacoub M.H. et al.Ross procedure in adults for cardiologists and cardiac surgeons: JACC state-of-the-art review.J Am Coll Cardiol. 2018; 72: 2761-2777Crossref PubMed Scopus (54) Google Scholar Drawbacks include the greater technical complexity of the Ross procedure than an isolated aortic valve replacement, trading single-valve disease for double-valve surveillance, and more difficult reoperations if the procedure ultimately fails. Reoperation for pulmonary autograft root dilation or autograft valve regurgitation typically consists of autograft removal and replacement with a mechanical or bioprosthetic valved-conduit. However, increasing familiarity with valve-sparing root replacement and aortic valve repair has led surgeons to preserve and/or repair the leaflets of the living autograft at the time of reoperation.4de Kerchove L. Boodhwani M. Etienne P.Y. Poncelet A. Glineur D. Noirhomme P. et al.Preservation of the pulmonary autograft after failure of the Ross procedure.Eur J Cardiothorac Surg. 2010; 38: 326-332Crossref PubMed Scopus (25) Google Scholar Although data are still limited, valve-sparing reoperations for failed pulmonary autografts carry low risk and low reintervention rates in the first decade postoperatively.5Mookhoek A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Failure requiring reintervention after the Ross procedure typically involves the pulmonary autograft. Mechanisms for failure include primary leaflet failure and dilation of the annulus, sinuses of Valsalva, or sinotubular junction.3Mazine A. El-Hamamsy I. Verma S. Peterson M.D. Bonow R.O. Yacoub M.H. et al.Ross procedure in adults for cardiologists and cardiac surgeons: JACC state-of-the-art review.J Am Coll Cardiol. 2018; 72: 2761-2777Crossref PubMed Scopus (54) Google Scholar,6Hokken R.B. Takkenberg J.J. van Herwerden L.A. Roelandt J.R. Bogers A.J. Excessive pulmonary autograft dilatation causes important aortic regurgitation.Heart. 2003; 89: 933-934Crossref PubMed Scopus (21) Google Scholar Groups that report exceedingly high rates of autograft failure have also demonstrated that much of the increase in neoaortic root diameter occurred before hospital discharge.6Hokken R.B. Takkenberg J.J. van Herwerden L.A. Roelandt J.R. Bogers A.J. Excessive pulmonary autograft dilatation causes important aortic regurgitation.Heart. 2003; 89: 933-934Crossref PubMed Scopus (21) Google Scholar Therefore, Ross procedure advocates employ technical modifications to promote long-term autograft durability by preventing dilation. One such technique includes implanting the autograft deeper—in an intra-annular fashion—so that the autograft annulus is stabilized by the native aortic annulus.3Mazine A. El-Hamamsy I. Verma S. Peterson M.D. Bonow R.O. Yacoub M.H. et al.Ross procedure in adults for cardiologists and cardiac surgeons: JACC state-of-the-art review.J Am Coll Cardiol. 2018; 72: 2761-2777Crossref PubMed Scopus (54) Google Scholar Another technique, which we prefer, includes externally supporting the autograft by reimplanting the entire pulmonic root within a Dacron graft and creating neosinuses with anticommissural plication (Figure 1, A) and then implanting into the aortic annulus (Figure 1, B). Patients at greater risk for autograft failure include those with native aortic annulus, root, or ascending aortic dilatation, and those with aortic insufficiency.7David T.E. Woo A. Armstrong S. Maganti M. When is the Ross operation a good option to treat aortic valve disease?.J Thorac Cardiovasc Surg. 2010; 139: 68-73Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar In these patients, adjunctive measures such as native aortic annuloplasty or external reinforcement of the autograft are employed. Of paramount importance is strict systemic blood pressure control (target <110 mm Hg) in the first year after surgery, which is believed to facilitate autograft adaptation to the systemic circulation. With these measures and technical considerations, a handful of groups report outstanding long-term pulmonary autograft durability.8David T.E. Ouzounian M. David C.M. Lafreniere-Roula M. Manlhiot C. Late results of the Ross procedure.J Thorac Cardiovasc Surg. 2019; 157: 201-208Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 9Martin E. Mohammadi S. Jacques F. Kalavrouziotis D. Voisine P. Doyle D. et al.Clinical outcomes following the ross procedure in adults: a 25-year longitudinal study.J Am Coll Cardiol. 2017; 70: 1890-1899Crossref PubMed Scopus (46) Google Scholar, 10Mastrobuoni S. de Kerchove L. Solari S. Astarci P. Poncelet A. Noirhomme P. et al.The Ross procedure in young adults: over 20 years of experience in our Institution.Eur J Cardiothorac Surg. 2016; 49: 507-512Crossref PubMed Scopus (45) Google Scholar, 11Sievers H.H. Stierle U. Charitos E.I. Takkenberg J.J.M. Hörer J. Lange R. et al.A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry.Eur J Cardiothorac Surg. 2016; 49: 212-218Crossref PubMed Scopus (75) Google Scholar With well more than 3000 patients who underwent the Ross procedure as adults between studies, estimated 20-year incidence of autograft reintervention ranged from 11% to 25%.8David T.E. Ouzounian M. David C.M. Lafreniere-Roula M. Manlhiot C. Late results of the Ross procedure.J Thorac Cardiovasc Surg. 2019; 157: 201-208Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 9Martin E. Mohammadi S. Jacques F. Kalavrouziotis D. Voisine P. Doyle D. et al.Clinical outcomes following the ross procedure in adults: a 25-year longitudinal study.J Am Coll Cardiol. 2017; 70: 1890-1899Crossref PubMed Scopus (46) Google Scholar, 10Mastrobuoni S. de Kerchove L. Solari S. Astarci P. Poncelet A. Noirhomme P. et al.The Ross procedure in young adults: over 20 years of experience in our Institution.Eur J Cardiothorac Surg. 2016; 49: 507-512Crossref PubMed Scopus (45) Google Scholar, 11Sievers H.H. Stierle U. Charitos E.I. Takkenberg J.J.M. Hörer J. Lange R. et al.A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry.Eur J Cardiothorac Surg. 2016; 49: 212-218Crossref PubMed Scopus (75) Google Scholar Some note that there is a slow deterioration of autograft valve function over time.8David T.E. Ouzounian M. David C.M. Lafreniere-Roula M. Manlhiot C. Late results of the Ross procedure.J Thorac Cardiovasc Surg. 2019; 157: 201-208Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,12Sievers H.H. Stierle U. Petersen M. Klotz S. Richardt D. Diwoky M. et al.Valve performance classification in 630 subcoronary Ross patients over 22 years.J Thorac Cardiovasc Surg. 2018; 156: 79-86Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The mechanism for failure—structural valve degeneration versus autograft root dilation—affects the possibility for sparing the autograft valve at the time of reintervention. Indications for reoperation on a failed autograft mirror those for native aortic insufficiency.3Mazine A. El-Hamamsy I. Verma S. Peterson M.D. Bonow R.O. Yacoub M.H. et al.Ross procedure in adults for cardiologists and cardiac surgeons: JACC state-of-the-art review.J Am Coll Cardiol. 2018; 72: 2761-2777Crossref PubMed Scopus (54) Google Scholar Reports of pulmonary autograft dissection are rare,13Peeters G. Arrigoni S.C. Schoof P. Accord R.E. Mariani M.A. Acute type A dissection 18 years after a Ross operation: the old prejudice.Ann Thorac Surg. 2019; 107: e255-e257Abstract Full Text Full Text PDF Google Scholar but it is reasonable to reintervene for aortic diameters >50 mm in the absence of autograft insufficiency. Reoperation after a Ross procedure is more complex and more akin to reoperative aortic root surgery than reoperation after conventional aortic valve replacement. Complexity further increases when both the pulmonary autograft and pulmonary homograft require reintervention. A surgeon must be comfortable with a variety of aortic and pulmonary root operations if reoperating on a patient after a Ross procedure. Despite this, mortality after reoperation for Ross failure is exceedingly low and ranges from 0% to 3% across published series.10Mastrobuoni S. de Kerchove L. Solari S. Astarci P. Poncelet A. Noirhomme P. et al.The Ross procedure in young adults: over 20 years of experience in our Institution.Eur J Cardiothorac Surg. 2016; 49: 507-512Crossref PubMed Scopus (45) Google Scholar,11Sievers H.H. Stierle U. Charitos E.I. Takkenberg J.J.M. Hörer J. Lange R. et al.A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry.Eur J Cardiothorac Surg. 2016; 49: 212-218Crossref PubMed Scopus (75) Google Scholar,14Mazine A. David T.E. Rao V. Hickey E.J. Christie S. Manlhiot C. et al.Long-term outcomes of the Ross procedure versus mechanical aortic valve replacement: propensity-matched cohort study.Circulation. 2016; 134: 576-585Crossref PubMed Scopus (71) Google Scholar As is true for other aortic operations,15Hughes G.C. Zhao Y. Rankin J.S. Scarborough J.E. O'Brien S. Bavaria J.E. et al.Effects of institutional volumes on operative outcomes for aortic root replacement in North America.J Thorac Cardiovasc Surg. 2013; 145: 166-170Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar,16Goldstone A.B. Chiu P. Baiocchi M. Lingala B. Lee J. Rigdon J. et al.Interfacility transfer of Medicare beneficiaries with acute type A aortic dissection and regionalization of care in the United States.Circulation. 2019; 140: 1239-1250Crossref PubMed Scopus (20) Google Scholar a positive volume–outcome relationship likely exists for Ross reoperations. The published series describing outcomes of reoperations after the Ross procedure are notably from expert centers. Therefore, the generalizability of their results is questionable. The pulmonary autograft valve may be spared at the time of reoperation to preserve the living-valve substitute, which does not require anticoagulation. In experienced hands, salvage of the autograft valve approaches or exceeds 50%,5Mookhoek A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,17Martin E. Laurin C. Jacques F. Houde C. Cote J.-M. Chetaille P. et al.More than 25 years of experience with the Ross procedure in children: a single-center experience.Ann Thorac Surg. 2020; 110: 638-644Abstract Full Text Full Text PDF Scopus (6) Google Scholar,18Liebrich M. Weimar T. Tzanavaros I. Roser D. Doll K.N. Hemmer W.B. The David procedure for salvage of a failing autograft after the Ross operation.Ann Thorac Surg. 2014; 98: 2046-2052Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar but this depends on the mechanism of autograft failure. Autograft valve-sparing reoperations may be performed at very low risk in experienced centers. In the largest multicenter experience of valve-sparing reoperations after the Ross procedure to date, Mookhoek and colleagues5Mookhoek A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar achieved a 1.2% operative mortality. In fact, despite longer operative times and nearly 1 in 5 patients undergoing concomitant replacement of the pulmonary outflow graft, the operative mortality achieved by these experienced surgeons falls within the range that the Society of Thoracic Surgeons risk calculator predicts for a reoperative aortic valve replacement if calculated for patients with the average characteristics of the study population. Although the low operative mortality may result from selecting healthier patients for valve-sparing procedures, it also speaks to the technical expertise of the surgeons who performed the operations in the multicenter study. Other case series affirm that autograft valve-sparing root replacements may be performed at low risk to the patient.19Ratschiller T. Eva S.D. Schimetta W. Paulus P. Müller H. Zierer A. et al.Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar However, one must take publication bias into consideration and one's own experience when considering whether these operations should be routinely performed. The available operations to spare the autograft valve depend on the mechanism of autograft failure. If the primary indication for reoperation is root aneurysm (Figure then a valve-sparing root replacement must be performed. root and root have for failed autografts. Although the available data not a in durability between and for sparing failed A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google T. Eva S.D. Schimetta W. Paulus P. Müller H. Zierer A. et al.Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar we the technique in (Figure A.B. Woo autograft leaflet repair and valve sparing root replacement to failure of the ross procedure.J Surg. 2013; PubMed Scopus Google A.B. Woo Autograft valve-sparing root replacement for Ross failure Thorac Cardiovasc Surg. 2017; PubMed Scopus Google Scholar The autograft root is and are in a to conventional reoperative root surgery, the autograft valve is (Figure B). is important to the aortic root to the may be difficult if the pulmonary homograft is very If one a into the Dacron graft to this to a graft of a graft and the graft by to the largest which through the aortic Baiocchi M. H. et of 5 for valve-sparing aortic root replacement a 2020; PubMed Scopus Google Scholar In most a graft is a graft is needed for and a graft is needed for the graft in a The are within the graft from one (Figure If is initial valve it be by the of the than the the the these be further than the The valve is after of the (Figure then be with or on the and the is the autograft valve is by blood the the graft an of the pressure the valve is also the and for the absence of blood within the of a of the aortic valve aortic with a to an is a good that very if blood is The is after the valve repair is that the pulmonary homograft does not to be it be through the annulus and into the outflow to (Figure The valve are (Figure and a bioprosthetic valve may be in a into the of the homograft at the to the pulmonary The of the outflow and pulmonary is with which is also to the of the bioprosthetic valve to the valve the pulmonary homograft be and with a pulmonary for reoperation is substantially with of a pulmonary homograft with a bioprosthetic valve the Ross H.H. Stierle U. Charitos E.I. Takkenberg J.J.M. Hörer J. Lange R. et al.A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry.Eur J Cardiothorac Surg. 2016; 49: 212-218Crossref PubMed Scopus (75) Google Scholar whether this relationship to those after valve-sparing is not When aortic is the primary indication for then an isolated valve repair with or annuloplasty may be for valve repair include those for of isolated aortic leaflet plication and However, the available data on isolated autograft valve repair are autograft valve isolated aortic and aortic regurgitation are the risk for reintervention after autograft valve-sparing Kerchove L. Boodhwani M. Etienne P.Y. Poncelet A. Glineur D. Noirhomme P. et al.Preservation of the pulmonary autograft after failure of the Ross procedure.Eur J Cardiothorac Surg. 2010; 38: 326-332Crossref PubMed Scopus (25) Google A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google G.B. G. F. G. G. Mazzucco A. surgery of the pulmonary experience with Ross J Cardiothorac Surg. PubMed Scopus Google Scholar is from the published data whether isolated autograft valve repair is typically or if the disease isolated aortic outcomes of valve-sparing reoperations. than likely it is the isolated aortic results from autograft which may a that or with may be to valve-sparing A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google T. Eva S.D. Schimetta W. Paulus P. Müller H. Zierer A. et al.Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar the very one must have an with the patient the durability of such a data after valve-sparing reoperations for failed pulmonary autografts are very series on a report years after valve-sparing A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google T. Eva S.D. Schimetta W. Paulus P. Müller H. Zierer A. et al.Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar after valve-sparing reoperations are not the patients who underwent valve-sparing reoperations in the multicenter patients surgical A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar the estimated incidence of reintervention at years high patients who underwent isolated autograft valve repair of and much patients who underwent autograft valve-sparing root replacement of In a series of patients who underwent autograft valve-sparing root replacement, the estimated incidence of reoperation at 5 years T. Eva S.D. Schimetta W. Paulus P. Müller H. Zierer A. et al.Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar this series not to spare valves with or leaflet the high reintervention rates associated with complex leaflet repair in this The initial type of Ross procedure root, or may the with which the autograft valve may be spared at A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The Ross is associated with a greater risk of reintervention after valve-sparing The this is that the native of the autograft root may be when within a graft, to and In root replacement most because of autograft which may be more to a valve-sparing after valve-sparing reoperation for Ross failure is excellent at A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google T. Eva S.D. Schimetta W. Paulus P. Müller H. Zierer A. et al.Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and supports the of a living-valve rates are with after the initial Ross T. T. D. de G. et al.The pulmonary autograft after the Ross operation: results of 25 year in a Thorac Surg. Full Text Full Text PDF Scopus (4) Google Scholar are than that of a the Ross procedure to aortic homograft root I. R. L. et al.Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve a 2010; Full Text Full Text PDF PubMed Scopus Google Scholar to valve-sparing reoperations after Ross failure our to aortic valve-sparing operations in not an after which a patient is longer a disease and for autograft leaflet repair are also not However, it is important to patients that the durability of a valve-sparing reoperation may be in the of disease of the autograft valve and aortic in the most experienced of reoperations should be when leaflet and are Kerchove L. Boodhwani M. Etienne P.Y. Poncelet A. Glineur D. Noirhomme P. et al.Preservation of the pulmonary autograft after failure of the Ross procedure.Eur J Cardiothorac Surg. 2010; 38: 326-332Crossref PubMed Scopus (25) Google A. de Kerchove L. El Khoury G. Weimar T. Luciani G.B. Mazzucco A. et al.European multicenter experience with valve-sparing reoperations after the Ross procedure.J Thorac Cardiovasc Surg. 2015; 150: 1132-1137Abstract Full Text Full Text PDF PubMed Scopus (22) Google T. Eva S.D. Schimetta W. Paulus P. Müller H. Zierer A. et al.Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure.J Thorac Cardiovasc Surg. 2018; 155: 2390-2397Abstract Full Text Full Text PDF PubMed Scopus (4) Google G.B. G. F. G. G. Mazzucco A. surgery of the pulmonary experience with Ross J Cardiothorac Surg. PubMed Scopus Google Scholar is substitute for the aortic valve in the young Surgeons must the risks and of a of in a and of patient and the Ross procedure for an operation is a difficult in and of and selecting to preserve the autograft valve after failure may be more The patient who a valve-sparing reoperation from this In the patient who reoperation for the autograft but A but of supports the and safety of valve-sparing reoperations for patients with a failed A of in the Ross procedure as a for aortic valve disease may the for autograft valve-sparing reoperations. As the experience with valve-sparing it is that we the long-term and very long-term results of these patients are still young at the time of very long-term with are The and of valve transcatheter and well as and surgical for valve as the may or to valve-sparing reoperations in the valve repair may a to Baiocchi M. H. et of 5 for valve-sparing aortic root replacement a 2020; PubMed Scopus Google Scholar of these the performance of the pulmonary autograft after the of valve-sparing reoperations is of surgeons have an of with which to the of autograft valve or root disease to The of The and to of and to or for which may have a of The and of this have of