Original Article
Replacement of the Aortic Root with a Pulmonary Autograft in Children and Young Adults with Aortic-Valve Disease
N Engl J Med 1994; 330:1-6January 6, 1994
- Abstract
Background
The optimal substitute for severely diseased aortic valves in children and young adults is unknown. The use of a mechanical prosthesis requires permanent treatment of the patient with anticoagulants and is associated with thromboembolic and hemorrhagic complications. Aortic-valve allografts and porcine bioprostheses, which do not necessitate anticoagulant therapy, may deteriorate and have limited durability.
Methods
We therefore evaluated the use of the autologous pulmonary valve (i.e., the patient's own pulmonary valve) and the adjacent pulmonary artery as a replacement for the aortic valve and aortic sinuses in 33 patients. Five of the patients were from 8 to 16 years of age, and 28 were from 20 to 47 years of age. The pulmonary valve and the main pulmonary artery were used to replace the diseased aortic valve and the adjacent aorta. The coronary arteries were detached from the aorta and implanted into the pulmonary artery. The pulmonary valve and artery were replaced with a cryopreserved pulmonary allograft.
Results
There were no deaths during follow-up of up to 48 months (mean, 21 months). There were no episodes of infective endocarditis, and no reoperations on the aortic root were necessary. Also, there was no evidence on echocardiography of progressive dilatation of the autografts. With color-flow Doppler imaging, 22 patients were found to have only trivial regurgitation or none, 9 patients to have mild regurgitation, and no patients to have moderate or severe regurgitation across the autograft at the most recent follow-up visit. The mean peak velocity of flow across the autograft was 1.3 m per second (upper limit of normal, 1.8), indicating the absence of stenosis. One patient required reoperation for stenosis of the pulmonary allograft.
Conclusions
Although the pulmonary-autograft procedure is more complex than simple aortic-valve replacement, it has been safely applied in selected patients, including young adults. Intermediate follow-up indicates satisfactory function of the autografts, with no dilatation or progressive valvular regurgitation. Pulmonary-root autografts may thus be the best available substitute for diseased aortic valves in children and young adults.
Media in This Article
Figure 1
Schematic Representation of the Operative Procedure.Figure 2
Serial Echocardiographic Assessments of the Severity of Regurgitation in the Pulmonary Autograft in 31 Patients.Article Activity
- Article
The optimal substitute for a diseased aortic valve in children and young adults has not been identified. Although several mechanical valves have satisfactory hemodynamic characteristics, all necessitate lifelong treatment of the patient with anticoagulants. Thromboembolism, hemorrhage, and prosthetic-valve endocarditis remain important complications1,2. Porcine bioprostheses, which do not necessitate long-term anticoagulation, deteriorate rapidly in young patients and have limited durability3. Aortic-valve allografts have excellent hydraulic function, necessitate no anticoagulant therapy, and are associated with a low incidence of thromboembolic complications. However, they also have limited durability in younger patients4-6. Because aortic-valve allografts are also used for other conditions (such as endocarditis, aneurysms that involve the aortic root, and reconstruction of the right ventricular outflow tract), they are not readily available.
In 1967, Ross7 described the use of the autologous pulmonary valve to replace the aortic valve. The valve was implanted within the aortic root, and the pulmonary valve was replaced with either an aortic or a pulmonary allograft. The viability of pulmonary-valve autografts in the aortic position has been documented, and they are more resistant to deterioration than aortic allografts6,8. The availability of commercially prepared, cryopreserved aortic-valve and pulmonary-valve allografts in recent years and the development of safe techniques for the replacement of the aortic root have broadened the indications for the replacement of the aortic root with either aortic allografts or pulmonary autografts to include patients with isolated aortic-valve disease8-11.
Replacement of the aortic root with a pulmonary-root autograft in patients with aortic-valve disease is an alternative to replacement of the aortic valve with a mechanical or bioprosthetic valve or an allograft. This approach should result in optimal hemodynamic function, since the pulmonary valve is approximately the same size as the aortic valve and is implanted with the adjacent sinuses of Valsalva. Also, the use of a pulmonary autograft should, in principle, eliminate thromboembolic complications without the need for anticoagulant therapy. In addition, these viable valves have the potential for growth,6,12 a particular advantage in children and young adults with aortic-valve disease. In this report we describe our experience in replacing the aortic root with a pulmonary autograft in 33 patients with aortic-valve disease and the results of serial echocardiographic studies assessing the function of these autografts and of the pulmonary allografts that were implanted in the right ventricular outflow tract.
Methods
Between June 1989 and May 1993, 33 patients with aortic-valve disease underwent replacement of the aortic root with a pulmonary autograft and replacement of the pulmonary root with a pulmonary allograft. The patients ranged in age from 8 to 47 years (mean, 31.4); 5 patients were from 8 to 16 years of age, and 28 were from 20 to 47 years of age. Twenty-two of the 33 were male. The indications for aortic-valve replacement are shown in Table 1Table 1
Indications for Aortic-Root Replacement.. A bicuspid aortic valve, present in 23 patients, was the most common indication for operation. The majority of these valves were heavily calcified; two of these patients also had aneurysms of the ascending aorta, which were replaced with Dacron grafts. Four patients had aortic regurgitation resulting from rheumatic heart disease, three had infective endocarditis, and three had failure of a previously inserted porcine bioprosthesis or mechanical valve. One of the 33 patients had previously undergone balloon valvuloplasty, and 8 had undergone one or more previous operations on the aortic valve. The patients were for the most part healthy and generally had good left ventricular function. The mean preoperative New York Heart Association functional class was 2.2 (on a 4-point scale, with 1 indicating no symptoms and 4 indicating symptoms at rest).Preoperative Evaluation
All the patients underwent preoperative left-heart catheterization and coronary arteriography to assess the severity of the aortic-valve disease and left ventricular dysfunction, to determine the size and location of the coronary arteries, and to determine the size and number of proximal septal perforating branches of the anterior descending coronary artery. These branches must be protected during the removal of the pulmonary valve and the adjacent right ventricular myocardium in order to prevent infarction of the ventricular septum13. Any large conal branches of the right coronary artery, which may connect with the anterior descending system and which may be injured during the removal of the pulmonary root, were also identified.
Operative Procedure
Intraoperative transesophageal two-dimensional and color-flow Doppler echocardiography was performed in most of the patients before cardiopulmonary bypass began in order to determine the diameter of the annulus and the sinuses of the pulmonary root and to assess the competence of the pulmonary valve. The size of the aortic annulus and the aortic sinuses was also measured. Mismatches in size of more than 2 to 3 mm between the aortic and pulmonary roots or more than trivial regurgitation in the pulmonary valve were not found in any of the patients. Patients with dilatation of the aortic root were not considered candidates for this procedure.
The technique for excision of the pulmonary root and its implantation into the aortic root is shown in Figure 1Figure 1
Schematic Representation of the Operative Procedure. 14. The procedure was performed during a period of cardiopulmonary bypass that averaged 199 minutes (range, 105 to 286). During the period of myocardial ischemia, which averaged 134 minutes (range, 70 to 200), the myocardium was protected by the infusion of cold blood (4 °C) or crystalloid cardioplegic solution directly into the coronary ostia or in a retrograde fashion into the coronary sinus. External cooling of the heart with iced crystalloid solution or with a cooling jacket was also used. After the discontinuation of cardiopulmonary bypass, the competence of the pulmonary-autograft valve and of the pulmonary-allograft valve in the right ventricular outflow tract was assessed by transesophageal echocardiography.Postoperative Evaluation and Management
Transthoracic M-mode, two-dimensional, color-flow, and Doppler echocardiograms were obtained before discharge from the hospital and every 6 to 12 months thereafter. The presence of regurgitation in the autograft was determined by continuous-wave, pulsed-wave, and color-flow Doppler methods. The severity of regurgitation was measured with the method of Perry et al.,15 in which the ratio of the width of the jet of regurgitation to the diameter of the left ventricular outflow tract at the level of the valve annulus is determined. This measurement has been shown to correlate well with the severity of aortic regurgitation as indicated by angiography15. A ratio of less than 0.2 was considered to indicate trivial regurgitation; a ratio of 0.2 to 0.39, mild regurgitation; 0.4 to 0.6, moderate regurgitation; and more than 0.6, severe regurgitation. A numerical grade was assigned to each of these ranges (Table 2Table 2
Echocardiographic Assessment of Regurgitation in the Autograft.). Using the method of Roman et al.,16 we measured the three dimensions of the pulmonary-root autograft at end-diastole: the diameter at the annulus, the maximal diameter of the sinuses of Valsalva, and the diameter at the supravalvular ridge. We also measured the peak velocity of the flow across the pulmonary-autograft and pulmonary-allograft valves in order to detect evidence of any obstruction of blood flow.The patients were evaluated at 6-to-12-month intervals after surgery for symptoms and signs of valve regurgitation and for other cardiac abnormalities. No patient was lost to follow-up. No anticoagulant or antiplatelet drugs were administered to any of the patients.
Statistical Analysis
The dimensions of the valve autograft were expressed as means ±SD. Repeated-measures analysis of variance was used to compare these measurements and the numerical values for the severity of regurgitation in the autograft at each echocardiographic study for each patient. A two-tailed P value of <0.05 was considered to indicate statistical significance.
Results
Mortality and Morbidity
There were no deaths in the hospital. One patient required early reoperation for bleeding. Twenty-two patients (67 percent) did not require transfusion of homologous blood products during the perioperative period. Fifteen of these patients had predeposited one or two units of autologous blood, which were transfused during or after the operation. In the 11 patients who required homologous blood, a mean of 2.7 units of red cells was transfused. There was no electrocardiographic or echocardiographic evidence of perioperative myocardial infarction in any patient. Seven patients had a pattern indicative of right bundle-branch block after the operation. In one patient, an eight-year-old child who had previously undergone balloon angioplasty of the aortic valve, complete heart block developed and implantation of a permanent pacemaker was required. One patient had partial homonymous hemianopia. This was probably the result of intraoperative embolization of a fragment from the severely diseased aortic valve. The median postoperative stay in the hospital was 7 days (range, 4 to 32).
There have been no deaths during the follow-up period, which at this writing extends to 48 months (mean duration of follow-up, 21 months), nor have there been any episodes of thromboembolism or infective endocarditis. No reoperations have been required on the valve autografts. One 15-year-old patient required reoperation for circumferential stenosis of the pulmonary allograft in the right ventricular outflow tract above the level of the pulmonary valve 16 months after the initial operation. The obstruction was successfully relieved with a pericardial patch. An aortic-root angiogram obtained immediately before the reoperation showed a normal-sized aortic root and no regurgitation in the autograft. The mean New York Heart Association class at the most recent follow-up was 1.0 for the 33 patients.
Echocardiographic Studies
Pulmonary-Autograft Function
The numerical grades for the severity of aortic-autograft regurgitation in 31 patients, as determined by echocardiography, are shown in Figure 2Figure 2
Serial Echocardiographic Assessments of the Severity of Regurgitation in the Pulmonary Autograft in 31 Patients.. At the initial postoperative study, performed in the first month after the operation, 29 patients had trivial regurgitation or none, and 4 patients had mild regurgitation. At the most recent follow-up study, 22 patients had only trivial or no regurgitation, 9 patients had mild regurgitation, and no patients had moderate or severe regurgitation across the autograft. Of the 16 patients who were examined 19 to 24 months postoperatively, 11 had trivial regurgitation or none, and 5 had mild regurgitation. For this subgroup, the mean regurgitation score was 0.34 ±0.30 at the initial postoperative examination and 0.52 ±0.44 at the later study (P = 0.3). For the group as a whole, there was no appreciable increase in the severity of regurgitation with time.Continuous-wave Doppler echocardiography across the pulmonary autograft at the initial postoperative study showed mildly increased flow velocity (from 2.0 to 2.2 m per second) in six patients (18 percent of the group). The upper limit of normal is 1.8 m per second. At the most recent examination, all values for velocity were within the normal range (mean, 1.3 m per second; range, 1.0 to 1.8). The early postoperative increase in velocity probably reflected a hyperdynamic state rather than valvular obstruction.
Dimensions of the Autograft
The mean values for the three diameters of the autograft (annulus, sinuses of Valsalva, and supravalvular ridge) soon after the operation and at the most recent follow-up visit (the interval between the two measurements was longer than three months for 31 patients) were as follows: 2.2 ±0.4 as compared with 2.2 ±0.3 cm at the annulus, 3.1 ±0.6 as compared with 3.3 ±0.5 cm at the sinuses of Valsalva, and 2.5 ±0.4 as compared with 2.6 ±0.4 cm at the supravalvular ridge. None of the differences were statistically significant. For the 16 patients who were examined early after surgery and 19 to 24 months thereafter, the mean diameters at the annulus were 2.3 ±0.3 and 2.3 ±0.3 cm, those at the sinuses of Valsalva were 3.3 ±0.5 and 3.4 ±0.6 cm, and those at the supravalvular ridge were 2.6 ±0.4 and 2.6 ±0.4 cm. These differences were also not statistically significant.
Pulmonary-Allograft Function
At the initial postoperative study, there was no regurgitation in the pulmonary-allograft valve in the right ventricular outflow tract in 18 patients and trivial or mild regurgitation in 13 patients. At the time of the most recent study, mild regurgitation had developed in three patients who initially had no pulmonary regurgitation, and three patients who initially had trivial regurgitation or none had no regurgitation.
At the initial study, continuous-wave Doppler echocardiography across the pulmonary allograft showed a mild overall elevation in systolic velocity (mean, 1.1 ±0.4 m per second; range, 0.6 to 2.0). The upper limit of normal for the native pulmonary valve is 0.8 m per second. These velocities returned to normal in later studies in most of the patients, suggesting that the early elevations were due to postoperative hemodynamic changes. During the follow-up period, however, seven patients were found to have moderate pressure gradients (mean, 26 ±14 mm Hg; range, 12 to 45), which were measured at a point distal to the pulmonary-allograft valve, primarily in the vicinity of the anastomosis between the arterial portion of the allograft and the native pulmonary artery. The gradients were confirmed by right-heart catheterization in two patients. In one of the patients, who had a measured gradient of 65 mm Hg at cardiac catheterization, the obstruction was surgically corrected.
Discussion
Although replacement of the aortic root with a pulmonary autograft in patients with isolated aortic-valve disease is a longer and more complex procedure than simple aortic-valve replacement, we and others12,17 have documented the safety of the procedure. In our series, there were no deaths in the hospital and no serious postoperative complications that could be attributed to the operative technique. With the methods of intraoperative myocardial protection that we employed, which included cold cardioplegia and surface cooling of the myocardium, intraoperative and postoperative myocardial dysfunction was minimal despite a duration of myocardial ischemia longer than that required for simple aortic-valve replacement. Only one third of the patients required transfusion of homologous blood products. Although there is the potential for injury to the septal branches of the left anterior descending coronary artery during the removal of the pulmonary root, no evidence of septal myocardial infarction was detected in any of the patients.
The advantages of using the pulmonary root as a substitute for the aortic root in patients with aortic-valve disease include the use of autologous tissue with documented long-term viability,8 the optimal or near-optimal alignment and function of the valve leaflets, since the sinuses of Valsalva are also transplanted, and the absence of substantial transvalvular pressure gradients, thromboembolism, and the need for anticoagulant therapy12. There is also evidence of growth of the autograft, which makes it an attractive option for aortic-valve replacement in infants and children6,12.
Aortic allografts that are implanted in the aortic root have hemodynamic characteristics that are similar to those of pulmonary autografts; they are also associated with a low incidence of thromboembolism and endocarditis, and they do not necessitate the use of anticoagulants or antiplatelet drugs. However, valve degeneration and reoperation because of mechanical failure occur more often in younger than in older patients4-6. In the experience of Gerosa et al.,9 aortic or pulmonary allografts that are implanted in the right ventricular outflow tract to replace the excised pulmonary root have a cumulative rate of freedom from valve failure or reoperation that exceeds 80 percent at 16 years. This freedom from valve failure or reoperation is superior to that for aortic allografts in the left ventricular outflow tract. Mild or moderate allograft stenosis or incompetence is likely to be tolerated better in the low-pressure right ventricular outflow tract than in the left ventricular outflow tract. Thus, the need for a second operation to remove a malfunctioning or degenerated allograft should be substantially reduced or possibly eliminated if the allograft is placed in the right ventricular rather than the left ventricular outflow tract.
The chief uncertainty regarding the use of pulmonary-root autografts in the aortic position is the potential for dilatation of the wall of the pulmonary artery and the development of progressive valvular regurgitation as a result of continued exposure to systemic pressure. Experimental studies by Gorczynski et al.18 have demonstrated that the leaflets of the pulmonary valve have a tensile strength that equals or exceeds that of aortic-valve leaflets. In an in vitro model of the circulation, Weerasena et al.19 observed a smaller drop in pressure across the pulmonic valve at systemic pressures than at pressures and flows that occur in the pulmonary artery. Furthermore, an increase in pressure had a limited effect on regurgitation in this model, and at the highest pressures most pulmonary valves closed completely, producing a competent valve19. Inward movement of the elastic arterial wall during diastole absorbs energy and reduces dynamic loading during closure19. These conditions may not exist when only the pulmonary valve or an aortic-allograft valve is implanted inside the aortic root, without the sinuses of Valsalva. Furthermore, the aortic wall to which a free pulmonary-valve autograft or aortic-valve allograft is attached may be noncompliant and may prevent the optimal functioning of the valve leaflets. There may also be misalignment of the valve commissures and cusps with a free graft, which will place greater stress on the valve components. These findings argue for the use of the entire pulmonary root rather than the pulmonary valve as a substitute for a diseased aortic valve.
Serial echocardiographic measurements of the three dimensions of the pulmonary-root autografts in 31 patients demonstrated no increase in the size of the autograft for up to 48 months after valve replacement (mean follow-up, 21 months). To our knowledge, this is the largest series of patients with pulmonary-root autografts in whom sequential measurements of these dimensions and semiquantitative estimates of the degree of aortic regurgitation have been performed.
Sievers et al.17 observed no significant increase in the diameter of seven pulmonary-root autografts at the commissural level in adult patients a mean of 12.5 ±7 months after surgery. Elkins et al.12 made sequential measurements of autografts in 13 of their 22 patients, all of whom were children. The mean duration of follow-up for their 21 surviving patients was approximately 21 months. Three patients were followed for more than 48 months, the longest follow-up being 58 months. Since growth occurred in many of these patients, it was not possible to differentiate clearly the growth of the pulmonary-root autograft from dilatation. The absence of progressive dilatation of the autograft in our patients was associated with an absence of progression of aortic regurgitation. Similar findings were reported by Sievers et al.17. Longer follow-up will be necessary to determine whether late changes will occur in the pulmonary arterial wall or in the pulmonary leaflets and whether such changes result in dilatation of the root and valvular regurgitation in the autograft.
Although replacement of the aortic root with a pulmonary root is a more complex operation than aortic-valve replacement in patients with aortic-valve disease, it has been used safely in a selected group of children and young adults with no early mortality or graft-related morbidity. Follow-up extending for as long as four years indicated excellent function of the autografts, with no evidence of dilatation or progressive valvular regurgitation. There have been no infectious or thromboembolic complications and no late deaths. If longer follow-up shows no evidence of the progression of regurgitation in the implanted valve, a pulmonary autograft may be the optimal substitute for a diseased aortic valve in children and young adults.
We are indebted to Drs. Donald Ross, Ronald Elkins, and John W. Kirklin for their advice and encouragement; to Dr. Thomas Wareing, who operated on one of the patients; and to Pamela Pigg and Nikki Gratigny for assistance in the preparation of the manuscript.
Source Information
From the Divisions of Cardiothoracic Surgery (N.T.K., T.L.S., S.F.M., J.B.P.) and Cardiology (V.G.D.-R.), Washington University School of Medicine, St. Louis.
Address reprint requests to Dr. Kouchoukos at the Department of Surgery, Jewish Hospital at Washington University Medical Center, 216 S. Kingshighway Blvd., St. Louis, MO 63110.
- References
References
1
Edmunds LH Jr . Thrombotic and bleeding complications of prosthetic heart valves. Ann Thorac Surg 1987;44:430-445
CrossRef | Web of Science | Medline2
Schenck MH ,Vaughn WK ,Reul GJ ,O'Laughlin MP . Long term follow-up in children and adolescents with left-sided artificial valves. J Am Coll Cardiol 1993;21:Suppl A:81A-81A abstract.3
al-Khaja N ,Belboul A ,Rashid M , et al. The influence of age on the durability of Carpentier-Edwards biological valves: thirteen years follow-up. Eur J Cardiothorac Surg 1991;5:635-640
CrossRef | Web of Science | Medline4
Radley-Smith R ,Fagan A ,Yacoub M . An eleven year experience of fresh aortic homograft replacement in children. Am J Cardiol 1982;49:1035-1035
CrossRef | Web of Science5
Barratt-Boyes BG ,Roche AHG ,Subramanyan R ,Pemberton JR ,Whitlock RML . Long-term follow-up of patients with the antibiotic-sterilized aortic homograft valve inserted freehand in the aortic position. Circulation 1987;75:768-777
CrossRef | Web of Science | Medline6
Gerosa G ,McKay R ,Davies J ,Ross DN . Comparison of the aortic homograft and the pulmonary autograft for aortic valve or root replacement in children. J Thorac Cardiovasc Surg 1991;102:51-61
Web of Science | Medline7
Ross DN . Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 1967;2:956-958
CrossRef | Web of Science | Medline8
Ross D ,Jackson M ,Davies J . The pulmonary autograft -- a permanent aortic valve. Eur J Cardiothorac Surg 1992;6:113-117
CrossRef | Web of Science | Medline9
Gerosa G ,McKay R ,Ross DN . Replacement of the aortic valve or root with a pulmonary autograft in children. Ann Thorac Surg 1991;51:424-429
CrossRef | Web of Science | Medline10
Stelzer P ,Jones DJ ,Elkins RC . Aortic root replacement with pulmonary autograft. Circulation 1989;80:Suppl III:III-20911
Kouchoukos NT ,Wareing TH ,Murphy SF ,Perrillo JB . Sixteen-year experience with aortic root replacement: results of 172 operations. Ann Surg 1991;214:308-320
CrossRef | Web of Science | Medline12
Elkins RC ,Santangelo K ,Randolph JD , et al. Pulmonary autograft replacement in children: the ideal solution? Ann Surg 1992;216:363-371
CrossRef | Web of Science | Medline13
Geens M ,Gonzalez-Lavin L ,Dawbarn C ,Ross DN . The surgical anatomy of the pulmonary artery root in relation to the pulmonary valve autograft and surgery of the right ventricular outflow tract. J Thorac Cardiovasc Surg 1971;62:262-267
Web of Science | Medline14
Ross D . Replacement of the aortic valve with a pulmonary autograft: the “switch” operation. Ann Thorac Surg 1991;52:1346-1350
CrossRef | Web of Science | Medline15
Perry GJ ,Helmcke F ,Nanda NC ,Byard C ,Soto B . Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol 1987;9:952-959
CrossRef | Web of Science | Medline16
Roman MJ ,Devereux RB ,Kramer-Fox R ,O'Loughlin J . Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol 1989;64:507-512
CrossRef | Web of Science | Medline17
Sievers HH ,Leyh R ,Loose R ,Guha M ,Petry A ,Bernhard A . Time course of dimension and function of the autologous pulmonary root in the aortic position. J Thorac Cardiovasc Surg 1993;105:775-780
Web of Science | Medline18
Gorczynski A ,Trenkner M ,Anisimowicz L , et al. Biomechanics of the pulmonary autograft valve in the aortic position. Thorax 1982;37:535-539
CrossRef | Web of Science | Medline19
Weerasena N ,Lockie KJ ,Butterfield M ,Fisher J ,Kearney JN ,Davies GA . The hydrodynamic function and leaflet dynamics of aortic and pulmonary roots and valves: an in vitro study. Eur J Cardiothorac Surg 1992;6:350-356
CrossRef | Web of Science | Medline
- Citing Articles (97)
Citing Articles
1
Francis Juthier, André Vincentelli, Claire Pinçon, Carlo Banfi, Pierre V. Ennezat, Sylvestre Maréchaux, Alain Prat. (2011) Reoperation After the Ross Procedure: Incidence, Management, and Survival. The Annals of Thoracic Surgery
CrossRef2
Paul Stelzer. (2011) The Ross Procedure: State of the Art 2011. Seminars in Thoracic and Cardiovascular Surgery 23:2, 115-123
CrossRef3
Hans-H. Sievers, Ulrich Stierle, Efstratios I. Charitos, Thorsten Hanke, Armin Gorski, Martin Misfeld, Matthias Bechtel. (2010) Fourteen years' experience with 501 subcoronary Ross procedures: Surgical details and results. The Journal of Thoracic and Cardiovascular Surgery 140:4, 816-822.e5
CrossRef4
Dilip S. Nath, Angela J. Shin, Daniel P. Nussbaum, Darren Berman, Vaughn A. Starnes, Winfield J. Wells. (2010) Ascending aortitis and aortic valve endocarditis in an infant. The Journal of Thoracic and Cardiovascular Surgery 139:4, e90-e91
CrossRef5
Johannes Nordmeyer, Philipp Lurz, Victor T. Tsang, Louise Coats, Fiona Walker, Andrew M. Taylor, Sachin Khambadkone, Marc R. de Leval, Philipp Bonhoeffer. (2009) Effective transcatheter valve implantation after pulmonary homograft failure: A new perspective on the Ross operation. The Journal of Thoracic and Cardiovascular Surgery 138:1, 84-88
CrossRef6
Laurent de Kerchove, Jean Rubay, Agnès Pasquet, Alain Poncelet, Caroline Ovaert, Manuel Pirotte, Michel Buche, William D'Hoore, Philippe Noirhomme, Gebrine El Khoury. (2009) Ross Operation in the Adult: Long-Term Outcomes After Root Replacement and Inclusion Techniques. The Annals of Thoracic Surgery 87:1, 95-102
CrossRef7
Robert O. Bonow, Blase A. Carabello, Kanu Chatterjee, Antonio C. de Leon, David P. Faxon, Michael D. Freed, William H. Gaasch, Bruce W. Lytle, Rick A. Nishimura, Patrick T. O'Gara, Robert A. O'Rourke, Catherine M. Otto, Pravin M. Shah, Jack S. Shanewise, Rick A. Nishimura, Blase A. Carabello, David P. Faxon, Michael D. Freed, Bruce W. Lytle, Patrick T. O'Gara, Robert A. O'Rourke, Pravin M. Shah. (2008) 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology 52:13, e1-e142
CrossRef8
Sara K. Pasquali, Bradley S. Marino, Jonathan R. Kaltman, Andrew J. Schissler, Gil Wernovsky, Meryl S. Cohen, Thomas L. Spray, Ronn E. Tanel. (2008) Rhythm and Conduction Disturbances at Midterm Follow-up After the Ross Procedure in Infants, Children, and Young Adults. The Annals of Thoracic Surgery 85:6, 2072-2078
CrossRef9
Bradley S. Marino, Sara K. Pasquali, Gil Wernovsky, Jack Rychik, Lisa Montenegro, David Shera, Thomas L. Spray, Meryl S. Cohen, Anita Pudusseri. (2008) Accuracy of Intraoperative Transesophageal Echocardiography in the Prediction of Future Neo-aortic Valve Function after the Ross Procedure in Children and Young Adults. Congenital Heart Disease 3:1, 39-46
CrossRef10
KHUNG KEONG YEO, REGINALD I. LOW. (2007) Aortic Stenosis: Assessment of the Patient at Risk. Journal of Interventional Cardiology 20:6, 509-516
CrossRef11
Sara K. Pasquali, David Shera, Gil Wernovsky, Meryl S. Cohen, Sarah Tabbutt, Susan Nicolson, Thomas L. Spray, Bradley S. Marino. (2007) Midterm outcomes and predictors of reintervention after the Ross procedure in infants, children, and young adults. The Journal of Thoracic and Cardiovascular Surgery 133:4, 893-899
CrossRef12
Duke E. Cameron, Luca A. Vricella. (2007) What is the proper place of the ross procedure in our modern armamentarium?. Current Cardiology Reports 9:2, 93-98
CrossRef13
Bruno Chiappini, Bruno Absil, Jean Rubay, Philippe Noirhomme, Jean-Christophe Funken, Robert Verhelst, Alain Poncelet, Gebrine El Khoury. (2007) The Ross Procedure: Clinical and Echocardiographic Follow-Up in 219 Consecutive Patients. The Annals of Thoracic Surgery 83:4, 1285-1289
CrossRef14
Giovanni Battista Luciani, Francesco Santini, Alessandro Mazzucco. (2007) Autografts, homografts, and xenografts: overview on stentless aortic valve surgery. Journal of Cardiovascular Medicine 8:2, 91-96
CrossRef15
Claudia Schmidtke, Gerlinde Dahmen, Bernhard Graf, Hans-H. Sievers. (2007) Pulmonary homograft muscle reduction to reduce the risk of homograft stenosis in the Ross procedure. The Journal of Thoracic and Cardiovascular Surgery 133:1, 190-195
CrossRef16
C. Schmidtke, G. Dahmen, H.-H. Sievers. (2006) Geschlechtsspezifische Aspekte nach pulmonalem Autograft (Ross-Operation). Zeitschrift für Herz-,Thorax- und Gefäßchirurgie 20:6, 229-235
CrossRef17
Antonios G. Mikos, Susan W. Herring, Pannee Ochareon, Jennifer Elisseeff, Helen H. Lu, Rita Kandel, Frederick J. Schoen, Mehmet Toner, David Mooney, Anthony Atala, Mark E. Van Dyke, David Kaplan, Gordana Vunjak-Novakovic. (2006) Engineering Complex Tissues. Tissue Engineering 12:12, 3307-3339
CrossRef18
Bradley S. Marino, Sara Pasquali, Thomas L. Spray, Gil Wernovsky. (2006) Is the Ross procedure as good as we thought it would be?. Cardiology in the Young 16:S3, 125
CrossRef19
Robert O. Bonow, Blase A. Carabello, Kanu Chatterjee, Antonio C. de Leon, David P. Faxon, Michael D. Freed, William H. Gaasch, Bruce Whitney Lytle, Rick A. Nishimura, Patrick T. O’Gara, Robert A. O’Rourke, Catherine M. Otto, Pravin M. Shah, Jack S. Shanewise, Sidney C. Smith, Alice K. Jacobs, Cynthia D. Adams, Jeffrey L. Anderson, Elliott M. Antman, David P. Faxon, Valentin Fuster, Jonathan L. Halperin, Loren F. Hiratzka, Sharon A. Hunt, Bruce W. Lytle, Rick Nishimura, Richard L. Page, Barbara Riegel. (2006) ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology 48:3, e1-e148
CrossRef20
Robert O. Bonow, Blase A. Carabello, Kanu Chatterjee, Antonio C. de Leon, David P. Faxon, Michael D. Freed, William H. Gaasch, Bruce Whitney Lytle, Rick A. Nishimura, Patrick T. O’Gara, Robert A. O’Rourke, Catherine M. Otto, Pravin M. Shah, Jack S. Shanewise, Sidney C. Smith, Alice K. Jacobs, Cynthia D. Adams, Jeffrey L. Anderson, Elliott M. Antman, David P. Faxon, Valentin Fuster, Jonathan L. Halperin, Loren F. Hiratzka, Sharon A. Hunt, Bruce W. Lytle, Rick Nishimura, Richard L. Page, Barbara Riegel. (2006) ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary. Journal of the American College of Cardiology 48:3, 598-675
CrossRef21
Mark E. Crowe, Cristiano A. Rocha, Edward Wu, James C. Carr. (2006) Complications Following the Ross Procedure. Journal of Thoracic Imaging 21:3, 213-218
CrossRef22
Paolo Zeppilli, Massimiliano Bianco, Serena Bria, Vincenzo Palmieri. (2006) Bicuspid aortic valve: an innocent finding or a potentially life-threatening anomaly whose complications may be elicited by sports activity?. Journal of Cardiovascular Medicine 7:4, 282-287
CrossRef23
Bradley S. Marino, Sara K. Pasquali, Gil Wernovsky, John R. Bockoven, Michael McBride, Catherine J. Cho, Thomas L. Spray, Stephen M. Paridon. (2006) Exercise performance in children and adolescents after the Ross procedure. Cardiology in the Young 16:01, 40
CrossRef24
Giovanni Battista Luciani, Alessandro Favaro, Gianluca Casali, Francesco Santini, Alessandro Mazzucco. (2005) Ross Operation in the Young: A Ten-Year Experience. The Annals of Thoracic Surgery 80:6, 2271-2277
CrossRef25
Cornelius A Botha. (2005) The Ross operation: utilization of the patient’s own pulmonary valve as a replacement device for the diseased aortic valve. Expert Review of Cardiovascular Therapy 3:6, 1017-1026
CrossRef26
Benjamin J. Pomerantz, Marc D. Krock, Jason R. Wollmuth, Brian P. Cupps, Nicholas T. Kouchoukos, Victor G. Davila-Roman, Michael K. Pasque. (2005) Aortic Valve Replacement for Aortic Insufficiency: Valve Type as a Determinant of Systolic Strain Recovery. Journal of Cardiac Surgery 20:6, 524-529
CrossRef27
F. Dagenais, P. Cartier, P. Voisine, D. Desaulniers, J. Perron, R. Baillot, G. Raymond, J. Métras, D. Doyle, P. Mathieu. (2005) Which biologic valve should we select for the 45- to 65-year-old age group requiring aortic valve replacement?. The Journal of Thoracic and Cardiovascular Surgery 129:5, 1041-1049
CrossRef28
Elena Rabkin-Aikawa, Masanori Aikawa, Mark Farber, Johannes R. Kratz, Guillermo Garcia-Cardena, Nicholas T. Kouchoukos, Max B. Mitchell, Richard A. Jonas, Frederick J. Schoen. (2004) Clinical pulmonary autograft valves: Pathologic evidence of adaptive remodeling in the aortic site. The Journal of Thoracic and Cardiovascular Surgery 128:4, 552-561
CrossRef29
Nicholas T. Kouchoukos, Paolo Masetti, Nancy J. Nickerson, Catherine F. Castner, William D. Shannon, Victor G. Dávila-Román. (2004) The Ross procedure: Long-term clinical and echocardiographic follow-up. The Annals of Thoracic Surgery 78:3, 773-781
CrossRef30
William M Novick, Darko Anic, Alfredo Lora Solf, Miguel Arboleda Torres, Ivan Niño De Guzmán León, Robert W Reid, Thomas G Di Sessa. (2004) Medtronic freestyle valve for right ventricular reconstruction in pediatric ross operations. The Annals of Thoracic Surgery 77:5, 1711-1716
CrossRef31
Giovanni Battista Luciani. (2004) Stentless aortic valve replacement: current status and future trends. Expert Review of Cardiovascular Therapy 2:1, 127-140
CrossRef32
David A Fullerton, James W Fredericksen, R.Sudhir Sundaresan, Keith A Horvath. (2003) The ross procedure in adults: intermediate-term results. The Annals of Thoracic Surgery 76:2, 471-477
CrossRef33
Jürgen O Böhm, Cornelius A Botha, Wolfgang Hemmer, Christoph Starck, Gunnar Blumenstock, Detlef Roser, Joachim-Gerd Rein. (2003) Older patients fare better with the Ross operation. The Annals of Thoracic Surgery 75:3, 796-801
CrossRef34
David Byron Redwine. (2002) Was Sampson wrong?. Fertility and Sterility 78:4, 686-693
CrossRef35
Neal D. Kon, Robert D. Riley, Sandy M. Adair, Dalane W. Kitzman, A.Robert Cordell. (2002) Eight-year results of aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis. The Annals of Thoracic Surgery 73:6, 1817-1821
CrossRef36
Bansi Koul, Carl-Johan Lindholm, Misha Koul, Anders Roijer. (2002) Ross Operation for Bicuspid Aortic Valve Disease in Adults: is it a Valid Surgical Option?. Scandinavian Cardiovascular Journal 36:1, 48-52
CrossRef37
SK Choudhary, A Govil, A Sampath Kumar. (2001) Ross procedure: Aortic valve replacement with pulmonary autograft. Indian Journal of Thoracic and Cardiovascular Surgery 17:4, 243-257
CrossRef38
Renzo Pessotto, Winfield J Wells, Craig J Baker, Carlos Luna, Vaughn A Starnes. (2001) Midterm results of the Ross procedure. The Annals of Thoracic Surgery 71:5, S336-S339
CrossRef39
P Simon. (2001) Growth of the pulmonary autograft after the Ross operation in childhood. European Journal of Cardio-Thoracic Surgery 19:2, 118-121
CrossRef40
Philippe Pibarot, Jean G Dumesnil. (2000) Hemodynamic and clinical impact of prosthesis–patient mismatch in the aortic valve position and its prevention. Journal of the American College of Cardiology 36:4, 1131-1141
CrossRef41
Claudia Schmidtke, J.F.Matthias Bechtel, Axel Noetzold, Hans-Hinrich Sievers. (2000) Up to seven years of experience with the Ross procedure in patients >60 years of age. Journal of the American College of Cardiology 36:4, 1173-1177
CrossRef42
Gustavo Abuin, Alejandro Nieponice, Silvio Martinez, Cichero Fernando. (2000) The role of atrial vessels in aortic root and mitral valve operations. The Annals of Thoracic Surgery 70:4, 1234-1237
CrossRef43
Rosenhek, Raphael, Binder, Thomas, Porenta, Gerold, Lang, Irene, Christ, Günther, Schemper, Michael, Maurer, Gerald, Baumgartner, Helmut, . (2000) Predictors of Outcome in Severe, Asymptomatic Aortic Stenosis. New England Journal of Medicine 343:9, 611-617
Full Text44
Christopher J Knott-Craig, Ronald C Elkins, KathyLee Santangelo, Carolyn McCue, Mary M Lane. (2000) Aortic valve replacement: comparison of late survival between autografts and homografts. The Annals of Thoracic Surgery 69:5, 1331-1332
CrossRef45
David A. Orsinelli, Curt J. Daniels. (2000) Aortic stenosis. Current Treatment Options in Cardiovascular Medicine 2:2, 117-124
CrossRef46
Lars G Svensson, James Longoria, Wendy A Kimmel, Edward Nadolny. (2000) Management of aortic valve disease during aortic surgery. The Annals of Thoracic Surgery 69:3, 778-783
CrossRef47
Tirone E. David, Ahmad Omran, Joan Ivanov, Susan Armstrong, Mauro P.L. de Sa, Brian Sonnenberg, Gary Webb. (2000) Dilation of the pulmonary autograft after the ross procedure. The Journal of Thoracic and Cardiovascular Surgery 119:2, 210-220
CrossRef48
Frederick J. Schoen, Robert J. Levy. (1999) Tissue heart valves: Current challenges and future research perspectives. Journal of Biomedical Materials Research 47:4, 439-465
CrossRef49
Michael A. Gatzoulis. (1999) Ross procedure: the treatment of choice for aortic valve disease?. International Journal of Cardiology 71:3, 205-206
CrossRef50
James H Oury, Bruce G Hardy, Hong He Luo, Matt Maxwell, Carlos M.G Duran. (1999) Expanding indications for the Ross procedure. The Annals of Thoracic Surgery 68:4, 1403-1406
CrossRef51
Karl M Dossche, Aart Brutel de la Riviére, Wim J Morshuis, Marc A.A.M Schepens, Sjef M Ernst, Jurriaan J van den Brand. (1999) Aortic root replacement with the pulmonary autograft: an invariably competent aortic valve?. The Annals of Thoracic Surgery 68:4, 1302-1307
CrossRef52
Kazuo Niwaya, Ronald C Elkins, Christopher J Knott-Craig, KathyLee Santangelo, M.Bruce Cannon, Mary M Lane. (1999) Normalization of left ventricular dimensions after ross operation with aortic annular reduction. The Annals of Thoracic Surgery 68:3, 812-818
CrossRef53
Robert A Puntel, Steven A Webber, Jose A Ettedgui, Theresa A Tacy. (1999) Rapid enlargement of neoaortic root after the Ross procedure in children. The American Journal of Cardiology 84:6, 747-749
CrossRef54
Neal D Kon, A.Robert Cordell, Sandy M Adair, John E Dobbins, Dalane W Kitzman. (1999) Aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis. The Annals of Thoracic Surgery 67:6, 1609-1615
CrossRef55
Nicholas T Kouchoukos. (1999) Aortic allografts and pulmonary autografts for replacement of the aortic valve and aortic root. The Annals of Thoracic Surgery 67:6, 1846-1848
CrossRef56
V Senthilnathan. (1999) Heart valves: which is the best choice?. Cardiovascular Surgery 7:4, 393-397
CrossRef57
Jean E Rubay, Michel Buche, Gébrine A El Khoury, Jean-Louis J Vanoverschelde, Thierry Sluysmans, Baudouin Marchandise, Jean-Claude Schoevaerdts, Robert A Dion. (1999) The Ross operation: mid-term results. The Annals of Thoracic Surgery 67:5, 1355-1358
CrossRef58
John D. Oswalt. (1999) Acceptance and versatility of the Ross procedure. Current Opinion in Cardiology 14:2, 90
CrossRef59
Giovanni Battista Luciani, Gianluca Casali, Francesco Santini, Alessandro Mazzucco. (1998) Aortic root replacement in adolescents and young adults: composite graft versus homograft or autograft. The Annals of Thoracic Surgery 66:6, S189-S193
CrossRef60
James H Oury, Donald B Doty, John D Oswalt, Joseph F Knapp, S.Katie Mackey, Carlos M.G Duran. (1998) Cardiopulmonary response to maximal exercise in young athletes following the Ross procedure. The Annals of Thoracic Surgery 66:6, S153-S154
CrossRef61
Alain Prat, Daniel Grandmougin, Christophe Decoene, François R Godart, José I Saez de Ibarra, Christine Savoye, Yves Goffin, Czeslas Stankowiak. (1998) Aortic root replacement with a pulmonary autograft in young adults: medium-term results in 70 patients. The Annals of Thoracic Surgery 66:6, S148-S152
CrossRef62
RobertO. Bonow, Blase Carabello, AntonioC. de Leon, L.Henry Edmunds, BradleyJ. Fedderly, MichaelD. Freed, WilliamH. Gaasch, CharlesR. McKay, RickA. Nishimura, PatrickT. O’Gara, RobertA. O’Rourke, ShahbudinH. Rahimtoola, JamesL. Ritchie, MelvinD. Cheitlin, KimA. Eagle, TimothyJ. Gardner, Arthur Garson, RaymondJ. Gibbons, RobertA. O’Rourke, RichardO. Russell, ThomasJ. Ryan, SidneyC. Smith. (1998) ACC/AHA guidelines for the management of patients with valvular heart disease. Journal of the American College of Cardiology 32:5, 1486-1582
CrossRef63
J.R Bockoven, Gil Wernovsky, Victoria L Vetter, Tammy S Wieand, Thomas L Spray, Larry A Rhodes. (1998) Perioperative conduction and rhythm disturbances after the Ross procedure in young patients. The Annals of Thoracic Surgery 66:4, 1383-1388
CrossRef64
Raymond B. Hokken, Hein G. de Bruin, Meindert A. Taams, Ad J. J. C. Bogers, Lex A. van Herwerden, Jos R. T. C. Roelandt, Egbert Bos, Matthijs Oudkerk. (1998) Gradient echo MRI for measurement of the pulmonary autograft diameter after transplantation to the aortic root: Validation and comparison with ultrasound. Journal of Magnetic Resonance Imaging 8:5, 1015-1021
CrossRef65
V.Mohan Reddy, Doff B. McElhinney, Colin K. Phoon, Michael M. Brook, Frank L. Hanley. (1998) Geometric mismatch of pulmonary and aortic anuli in children undergoing the Ross procedure: Implications for surgical management and autograft valve function. The Journal of Thoracic and Cardiovascular Surgery 115:6, 1255-1263
CrossRef66
Paul H. Schoof, Mark G. Hazekamp, Gijs van Wermeskerken, Emile de Heer, Jan A. Bruijn, Adriana Gittenberger-de Groot, Hans A. Huysmans. (1998) Disproportionate enlargement of the pulmonary autograft in the aortic position in the growing pig. The Journal of Thoracic and Cardiovascular Surgery 115:6, 1264-1272
CrossRef67
James H. Oury. (1998) On The Ross Procedure. Journal of Cardiac Surgery 13:3, 171-172
CrossRef68
Paul Stelzer, Susanne Weinrauch, Robert F. Tranbaugh. (1998) Ten years of experience with the modified Ross procedure. The Journal of Thoracic and Cardiovascular Surgery 115:5, 1091-1100
CrossRef69
Francisco Costa, Hermínio Haggi, Rita Pinton, Walmor Lenke, Eduardo Adam, Iseu S. E. A. Costa. (1998) Rest and Exercise Hemodynamics After the Ross Procedure: An Echocardiographic Study. Journal of Cardiac Surgery 13:3, 177-185
CrossRef70
Ronald C Elkins, Christopher J Knott-Craig, Kent E Ward, Mary M Lane. (1998) The Ross Operation in Children: 10-Year Experience. The Annals of Thoracic Surgery 65:2, 496-502
CrossRef71
R Moidl. (1997) Increased pulmonary flow velocities in oversized homografts in patients after the Ross procedure. European Journal of Cardio-Thoracic Surgery 12:4, 569-573
CrossRef72
Dimitrios Dougenis, Bill B Daily, Nicholas T Kouchoukos. (1997) Reoperations on the Aortic Root and Ascending Aorta. The Annals of Thoracic Surgery 64:4, 986-992
CrossRef73
Francesco Santini, Cornelius Dyke, Sue Edwards, George Stavri, Mariano Feccia, Hasnat Khan, Emma Birks, Magdi H. Yacoub. (1997) Pulmonary autograft versus homograft replacement of the aortic valve: A prospective randomized trial. The Journal of Thoracic and Cardiovascular Surgery 113:5, 894-900
CrossRef74
Raymond B. Hokken, Ad J.J.C. Bogers, Meindert A. Taams, Mieke B. Schiks-Berghourt, Lex A. van Herwerden, Jos R.T.C. Roelandt, Egbert Bos. (1997) Does the pulmonary autograft in the aortic position in adults increase in diameter? An echocardiographic study. The Journal of Thoracic and Cardiovascular Surgery 113:4, 667-674
CrossRef75
Kiyoyuki Eishi, MD, Shunsuke Nakajima, MD, Kiyoharu Nakano, MD, Yoshio Kosakai, MD, Norifumi Nakanishi, MD, Toshikatsu Yagihara, MD, Shinichi Takamoto, MD. (1997) Pulmonary Autograft Implantation in the Dilated Aortic Annulus. The Annals of Thoracic Surgery 63:4, 1155-1157
CrossRef76
Masamichi Miura, Yasuhisa Shimazaki, Tako Watanabe, Yoshiyuki Iijima, Setuo Kuraoka, Kiyoshige Inui, Tadashi Oshikiri, Tetsuro Uchida, Mituro Nakasato. (1997) Bentall Operation for a Child with Marfan Syndrome: A Case Report. Journal of Cardiac Surgery 12:2, 116-119
CrossRef77
Raymond B. Hokken, Margot M. Bartelings, Ad J.J.C. Bogers, Adriana C. Gittenberger-de Groot. (1997) Morphology of the pulmonary and aortic roots with regard to the pulmonary autograft procedure. The Journal of Thoracic and Cardiovascular Surgery 113:3, 453-461
CrossRef78
Michael J Tolan, FRCS(I), Piers E Daubeney, MB, BS, Zdenek Slavik, MD, Barry R Keeton, FRCP, Anthony P Salmon, FRCP, James L Monro, FRCS. (1997) Aortic Valve Repair of Congenital Stenosis With Bovine Pericardium. The Annals of Thoracic Surgery 63:2, 465-469
CrossRef79
Tirone E. David, Ahmed Omran, Gary Webb, Harry Rakowski, Susan Armstrong, Zhao Sun. (1996) Geometric mismatch of the aortic and pulmonary roots causes aortic insufficiency after the Ross procedure. The Journal of Thoracic and Cardiovascular Surgery 112:5, 1231-1239
CrossRef80
Göran Südow, Laszlo Solymar, Håkan Berggren, Bengt Eriksson, Daniel Holmgren, Tomas Gilljam. (1996) Aortic valve replacement with a pulmonary autograft in infants with critical aortic stenosis. The Journal of Thoracic and Cardiovascular Surgery 112:2, 433-436
CrossRef81
Ronald C. Elkins, Mary M. Lane, Carolyn McCue. (1996) Pulmonary autograft reoperation: Incidence and management. The Annals of Thoracic Surgery 62:2, 450-455
CrossRef82
J Melo. (1996) What are the limits for the Ross operation?. Cardiovascular Surgery 4:4, 526-529
CrossRef83
Ronald C. Elkins, Christopher J. Knott-Craig, C. Eric Howell. (1996) Pulmonary autografts in patients with aortic annulus dysplasia. The Annals of Thoracic Surgery 61:4, 1141-1145
CrossRef84
V.Mohan Reddy, Hiranya A. Rajasinghe, David F. Teitel, Gary S. Haas, Frank L. Hanley. (1996) Aortoventriculoplasty with the pulmonary autograft: The "Ross-Konno" procedure. The Journal of Thoracic and Cardiovascular Surgery 111:1, 158-167
CrossRef85
I Vesely. (1995) New concepts in the design and use of biological prosthetic valves. Cardiovascular Pathology 4:4, 287-291
CrossRef86
Valter C. Lima, Charles Lazzam, Lee N. Benson. (1995) Stenting for pulmonary artery stenosis following the ross procedure. Catheterization and Cardiovascular Diagnosis 36:3, 259-261
CrossRef87
Tineke P. Willems, Lex A. van Herwerden, Ewout W. Steyerberg, Meindert A. Taams, Veronica E. Kleyburg, Raymond B. Hokken, Jos R.T.C. Roelandt, Egbert Bos. (1995) Subcoronary implantation or aortic root replacement for human tissue valves: Sufficient data to prefer either technique?. The Annals of Thoracic Surgery 60, S83-S86
CrossRef88
Zohair Al-Halees, Naresh Kumar, Ricardo Gallo, Begonia Gometza, Carlos M.G. Duran. (1995) Pulmonary autograft for aortic valve replacement in rheumatic disease: A caveat. The Annals of Thoracic Surgery 60, S172-S176
CrossRef89
Ellis L. Jones, Vipul B. Shah, Jack S. Shanewise, Tomas D. Martin, Randolph P. Martin, Jorge A. Coto, Ruth Broniec, Yannan Shen. (1995) Should the freehand allograft be abandoned as a reliable alternative for aortic valve replacement?. The Annals of Thoracic Surgery 59:6, 1397-1404
CrossRef90
Alessandro Giamberti, Salvatore Giannico, Cosimo Squitieri, Fiore S. Iorio, Antonio Amodeo, Adriano Carotti, Sergio Picardo, Carlo Marcelletti. (1995) Neonatal pulmonary autograft implantation for cardiac tumor involving aortic valve. The Annals of Thoracic Surgery 59:5, 1219-1221
CrossRef91
Serafin Y. DeLeon, Jose A. Quinones, Ronald H. Miles, Joanne Hofstra, Timothy J. Bell, Elizabeth A. Fisher, Roque Pifarré. (1995) Use of the native aortic valve as the pulmonary valve in the Ross procedure. The Annals of Thoracic Surgery 59:4, 1007-1010
CrossRef92
Neal D. Kon, Stephen Westaby, Naomali Amarasena, Ravi Pillai, A. Robert Cordell. (1995) Comparison of implantation techniques using freestyle stentless porcine aortic valve. The Annals of Thoracic Surgery 59:4, 857-862
CrossRef93
Alan J. Bryan, Benico Barzilai, Nicholas T. Kouchoukos. (1995) Transesophageal echocardiography and adult cardiac operations. The Annals of Thoracic Surgery 59:3, 773-779
CrossRef94
David B. Ross, George A. Trusler, John G. Coles, Ivan M. Rebeyka, Jeffrey Smallhorn, William G. Williams, Robert M. Freedom. (1994) Small aortic root in childhood: Surgical options. The Annals of Thoracic Surgery 58:6, 1617-1624
CrossRef95
(1994) Replacement of the Aortic Root with a Pulmonary Autograft. New England Journal of Medicine 330:22, 1615-1616
Full Text96
Tom Treasure. (1994) The pulmonary autograft as an aortic valve replacement. The Lancet 343:8909, 1308
CrossRef97
Elkins, Ronald C., . (1994) Pulmonary Autograft -- The Optimal Substitute for the Aortic Valve?. New England Journal of Medicine 330:1, 59-60
Full Text
- Letters
