Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation

Number: 0407

Policy

  1. Aetna considers the Ross pulmonary autograft procedure medically necessary for members undergoing aortic valve replacement secondary to either congenital anomalies or aortic valve disease, such as:

    1. Aortic incompetence (including endocarditis, rheumatism of the heart); or
    2. Aortic stenosis; or
    3. Complex left ventricular outflow tract obstruction; or
    4. Congenital lesions.

    Contraindications to this procedure are presented as an Appendix to the Background section.

    Aetna considers the Ross pulmonary autograft experimental and investigational for all other indications (e.g., middle-aged or older adults when suitable alternatives to autograft replacement of the aortic valve are available with comparable results and without the need for replacement of the right ventricular outflow tract, and individuals with bicuspid valves and aortic regurgitation or aortic dilation if other alternatives are available) because its effectiveness for indications other than the ones listed above has not been established.

  2. Aetna considers the minimally invasive approach to the aortic valve a medically necessary acceptable alternative to the conventional approach to aortic valve replacement.

  3. Aetna considers aortic valve-sparing re-implantation medically necessary for the treatment of secondary aortic regurgitation due to aortic root dilatation as occurs in Marfan syndrome as well as for the treatment of type A acute aortic dissections (i.e., dissection of the ascending and descending aorta).

    Aetna considers aortic valve-sparing re-implanatation experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.

  4. Aetna considers aortic valve-sparing procedures medically necessary for the treatment of aortic root ectasia, and dissection and aneurysms of the ascending aorta.

  5. Aetna considers the decellularized Matrix P bioprosthesis experimental and investigational for pulmonary valve replacement for Ross procedures because the safety and effectiveness of this approach has not been established.

  6. Aetna considers the Florida Sleeve valve-sparing procedure experimental and investigational for the treatment of aortic root ectasia and aneurysm because the long-term safety and effectiveness of this approach has not been established.

Background

Patients undergoing aortic valve replacement may consider 3 options:
  1. a prosthetic valve,
  2. a homograft valve, or
  3. a pulmonary autograft (i.e., the Ross procedure).

Ross pulmonary autograft refers to essentially a double valve replacement in which the native pulmonic valve is substituted for the diseased aortic valve, while a homograft prosthetic valve replaces the pulmonic valve.  This procedure was first devised in 1967 and sought to provide a permanent aortic valve substitution, which would not degenerate like a homograft valve and would not require chronic anti-coagulation therapy like a prosthetic valve.  The risk:benefit ratio involves a balance between a more complicated surgical procedure (essentially a double valve replacement) and a potentially more durable and physiologic aortic valve replacement.  Furthermore, it is thought that the autografted pulmonary valve will grow with the young patient, thus obviating the need for re-operation.  Studies have also shown that the Ross procedure resulted in significant improvement in left ventricular wall thickness and outflow tract velocity not observed in allograft aortic valve replacements in children.  For these reasons, the Ross procedure is considered most appropriate for young adults.  Candidates for this procedure should be adequately counseled on the various valve replacement alternatives.

In a systematic review and meta-analysis, Takkenberg et al (2009) stated that the Ross procedure provides satisfactory results for both children and young adults (less than or equal to 50 years of age).  Furthermore, David (2009) noted that young adults with aortic stenosis and normal-size aortic root are the best candidates for the Ross procedure.

Aortic valve-sparing re-implantation is a valve-sparing technique employed for patients with aortic regugitation secondary to aortic root dilatation in which valvular insufficiency is due to outward displacement of the valve commissures.  This technique, which is different from aortic valve repair, has the advantages of lack of requirement for anti-coagulation and avoidance of other problems and complications associated with mechanical prosthetic valves.  Although primarily used for secondary aortic regurgitation due to root dilatation as occurs in Marfan syndrome, guidelines from the European Society of Cardiology (Erbel et al, 2001) stated that aortic valve-sparing re-implantation may also be indicated for patients with type A acute aortic dissections (i.e., dissection of the ascending and descending aorta).

The Society of Thoracic Surgeons’ “Aortic valve and ascending aorta guidelines for management and quality measures” (Svensson et al, 2013) stated that

  • The Ross procedure is not recommended for middle-aged or older adults when suitable alternatives to autograft replacement of the aortic valve are available with comparable results and without the need for replacement of the right ventricular outflow tract (RVOT), as the latter adds the additional risk of pulmonary valve dysfunction and subsequent replacement.  (Level of evidence C)
  • The Ross procedure is not recommended for patients with bicuspid valves and aortic regurgitation or aortic dilation if other alternatives are available.  (Level of evidence C)

Guidelines from the European Society of Cardiology (Erbel, et al., 2014) state that In most cases of aortic insufficiency associated with acute Type A dissection, the aortic valve is essentially normal and can be preserved by applying an aortic valve-sparing repair of the aortic root. In cases of aneurysms of the ascending aorta, where total replacement is indicated, the choice between a valve-sparing intervention and a composite graft with a valve prosthesis depends on the analysis of aortic valve function and anatomy, the size and site of TAA, life expectancy, desired anticoagulation status, and the experience of the surgical team.

Similarly, guidelines from the American College of Cardiology (Hiratzka, et al., 2010) state that extensive dissection of the aortic root should be treated with aortic root replacement with a composite graft or with a valve sparing root replacement.

Stephens et al (2014) examined if recurrent or residual mild aortic regurgitation, which occurs after valve-sparing aortic root replacement, progresses over time.  Between 2003 and 2008, a total of 154 patients underwent Tirone David-V valve-sparing aortic root replacement; 96 patients (62 %) had both 1-year (median of 12 ± 4 months) and mid-term (62 ± 22 months) transthoracic echocardiograms available for analysis.  Age of patients averaged 38 ± 13 years, 71 % were male, 31 % had a bicuspid aortic valve, 41 % had Marfan syndrome, and 51 % underwent aortic valve repair, predominantly cusp free margin shortening.  A total of 41 patients (43 %) had mild aortic regurgitation on 1-year echocardiogram.  In 85 % of patients (n = 35), mild aortic regurgitation remained stable on the most recent echocardiogram (median of 57 ± 20 months); progression to moderate aortic regurgitation occurred in 5 patients (12 %) at a median of 28 ± 18 months and remained stable thereafter; severe aortic regurgitation developed in 1 patient, eventually requiring re-operation.  Five patients (5 %) had moderate aortic regurgitation at 1 year, which did not progress subsequently.  Two patients (2 %) had more than moderate aortic regurgitation at 1 year, and both ultimately required re-operation.  The authors concluded that although mild aortic regurgitation occurs frequently after valve-sparing aortic root replacement, it is unlikely to progress over the next 5 years and should not be interpreted as failure of the valve-preservation concept.  Further, these investigators suggested that mild aortic regurgitation should not be considered non-structural valve dysfunction, as the 2008 valve reporting guidelines would indicate.  The authors noted that 10- to 15-year follow-up is needed to learn the long-term clinical consequences of mild aortic regurgitation early after valve-sparing aortic root replacement.

In a retrospective study, Gamba and colleagues (2015) evaluated their experience of using a simplified aortic valve sleeve procedure to treat aortic root ectasia and aneurysms with or without aortic regurgitation.  In experienced hands, 2 aortic valve-sparing procedures, namely, Yacoub and David, have yielded excellent long-term results in the treatment of aortic root aneurysms, with or without aortic regurgitation.  However, these techniques are demanding and not widely used.  Recently, a new and simplified valve-sparing technique, named "sleeve procedure", has been proposed, and has yielded encouraging early results.  A total of 90 consecutive patients with aortic root aneurysms underwent sleeve procedures from October 2006 to October 2012.  Follow-up data (clinical 100 % complete and echocardiographic 93 % complete) were acquired from the authors’ out-patient clinic or from the referring cardiologist.  The mean age of the patients was 61.5 ± 12.5 years, 79 % were male, 16 (18 %) had a bicuspid valve, 3 had Marfan syndrome, and 2 had aortic dissection.  Over a mean clinical follow-up of 34 ± 19 months, 2 patients died from non-cardiac causes and 1 was re-operated on for the recurrence of aortic regurgitation.  On follow-up echocardiography after a mean of 18 ± 9 months, aortic regurgitation was absent/negligible, mild or moderate in 62 %, 37 %, and 1 % of patients, respectively, and the diameters of the annulus, Valsalva sinuses, and sino-tubular junction were 27.3 + 2.2, 37.0 + 3.4, and 30.6 + 3.1 mm, respectively.  The authors concluded that these encouraging early and medium term results suggested that the sleeve procedure is a safe and effective aortic valve-sparing technique for the treatment of aortic root ectasia and aneurysm.  However, they stated that longer follow-up is needed in order to draw definitive conclusions.

Bavaria and colleagues (2015) noted that valve-sparing root reimplantation (VSRR) in tricuspid aortic valve (TAV) patients is well-established, but in bicuspid aortic valve (BAV) patients, it has been less widely adopted. These investigators examined if valve type affects mid-term outcomes with VSRR.  They performed a retrospective review of 186 patients who underwent an aortic valve-sparing root reimplantation operation between 2004 and 2013.  Of these, 129 patients underwent elective VSRR with the David V technique.  Outcomes were compared in this cohort by valve type: TAV (n = 89) versus BAV (n = 40).  Demographics were similar in the 2 groups -- BAV patients had a higher degree of aortic insufficiency (AI) at presentation (p < 0.05), and an enlarged pre-operative annulus (30 ± 4 versus 28 ± 6 mm, p = 0.06).  All BAV patients required primary leaflet repair (6 % in the TAV group; p < 0.01).  Post-operative mortality (0), stroke (0 % versus 1 %), and pacemaker requirement (0 % versus 5 %) were similar.  Post-operative freedom from AI grade greater than or equal to 2+ was 100 % in the entire cohort, and trans-valvular gradients were similar.  At follow-up, a 1-year echocardiogram (ECG) showed higher peak and mean trans-valvular gradients in the BAV group (p < 0.01).  One TAV group patient died from an unknown cause.  The 5-year actuarial freedom from aortic valve reoperation was 100 % versus 97 % ± 3 % (p = 0.6); 3 patients in the entire cohort have had AI grade greater than 2+ on follow-up (n = 1 in the BAV group; n = 2 in the TAV group).  The authors concluded that even though BAV patients presented with higher AI grade and required concomitant primary valve repair, the VSRR David V technique offered excellent mid-term outcomes with both the BAV and TAV valve types.

Malvindi and associates (2015) stated that aortic valve-sparing operation has been progressively widely performed for the treatment of aortic root aneurysm. Nowadays, this procedure has been proposed even in presence of a BAV, severe aortic regurgitation or in primary aortic dissection repair.  These investigators presented their 10-year experience focusing on mid-term ECG follow-up.  Between June 2002 and February 2012, a total of 139 patients (mean age of 61 ± 12 years) underwent aortic valve-sparing operation with valve reimplantation; 27 patients (19 %) had BAV; in 18 cases (13 %) cusp motion or anatomical abnormalities concurred in determining aortic regurgitation and needed an adjunct cusp repair.  A Gelweave Valsalva graft was implanted in all the patients.  The mortality pre-discharge was 0.7 % (1 patient).  The cumulative 1-year, 5-years and 8-years survival rates were 99 %, 93 % and 87 %, respectively.  Post-operative aortic regurgitation more than mild degree (greater than 2+/4+) was the only significant risk factors for redo aortic valve surgery freedom from reoperation due to aortic valve regurgitation was 96 % at 1 year, 90 % at 5 years and 86 % at 8 years.  When comparing freedom from reoperation in patients with BAV versus TAV, no differences were found (p = 0.31) and the rate of aortic valve reoperation was significantly higher (p < 0.001) in patients who received leaflet's repair.  The authors concluded that the durability of valve reimplantation was found to be excellent in patients with TAV and normal or nearly normal cusps.  Cusp prolapse and complication after cusp repair turned out to be the main causes for early failure.

The Ross Procedure versus Other Aortic Valve Replacement

Um and colleagues (2018) noted that life expectancy in young adults undergoing mechanical or bioprosthetic aortic valve replacement (AVR) may be reduced by up to 20 years compared to age-matched controls.  The Ross procedure is a durable, anticoagulation-sparing alternative.  These investigators performed a systematic review and meta-analysis to compare the valve hemodynamics of the Ross procedure versus other AVR.  They searched Cochrane CENTRAL, Medline and Embase from inception to February 2017 for randomized controlled trials (RCTs) and observational studies (n of greater than or equal to 10 Ross).  Independently and in duplicate, these researchers performed title and abstract screening, full-text eligibility assessment, and data collection.  They evaluated the risk of bias with the Cochrane and CLARITY tools, and the quality of evidence with the GRADE framework.  The authors identified 2 RCTs and 13 observational studies that met eligibility criteria (n = 1,412).  In observational studies, the Ross procedure was associated with a lower mean aortic gradient at discharge (mean difference [MD] -9 mmHg, 95 % confidence interval [CI]: -13 to -5, p < 0.0001, I2 = 97 %) and latest follow-up (MD -5 mmHg, 95 % CI: -7 to -3, p < 0.0001, I2 = 92 %).  There was no significant difference in the incidence of severe aortic regurgitation at latest follow-up (relative risk [RR] 1.3, 95 % CI: 0.3 to 5.8, p = 0.70, I2 = 30 %).  In RCTs, the Ross procedure was associated with a lower mean gradient at latest follow-up (MD -15 mmHg, 95 % CI: -32 to 2, p = 0.08, I2 = 99 %).  The mean pulmonic gradient for the Ross procedure was 18.0 mmHg (95 % CI: 16 to 20, p < 0.0001) at latest follow-up.  The evidence for all outcomes from observational studies was deemed to be of very low quality, while the evidence from RCTs was down-graded for imprecision and moderately serious risk of bias.  The authors concluded that compared to conventional AVR, the Ross procedure was associated with better aortic valve hemodynamics.  These researchers stated that future studies should evaluate the impact of the Ross procedure on exercise capacity and quality of life (QOL).

Decellularized Matrix P Bioprosthesis for Pulmonary Valve Replacement for Ross Procedures

Christ and colleagues (2019) noted that since 1967, the Ross procedure has been performed to treat aortic valve disease using homografts for pulmonary valve replacement (PVR). The decellularized Matrix P bioprosthesis was developed to overcome (some) limitations of homografts.  Until now, the long-term outcome data have been unavailable.  Between 2002 and 2010, the Ross procedures using the Matrix P bioprosthesis were performed in 492 adult patients (mean age of 57.2 ± 10.6 years, range of 21 to 73 years) at the authors’ institution.  Patient data were prospectively collected and analyzed (3,617.3 patient-years, mean follow-up of 7.7  ±  4.3 years).  Completeness of follow-up at 1, 5 and 10 years was 98.4 %, 94.5 % and 91.0 %, respectively.  Hospital mortality was 3.9 % (n  = 19).  During follow-up, 121 patients died resulting in a survival rate at 5, 10 and 12.5 years of 82.8  ±  1.7 %, 70.4  ±  2.3 %, and 62.4  ±  2.9 %, respectively.  Echocardiography revealed a high incidence of relevant dysfunction of the Matrix P bioprosthesis and subsequent right ventricular failure.  Primary re-operation/re-intervention was necessary for 150 Matrix P and 48 autografts.  Freedom from pulmonary valve re-operation at 5, 10 and 12.5 years was 76.2  ±  2.1 %, 58.6  ±  2.9 % and 53.4  ±  3.4 %, respectively.  The autograft function and the left ventricular function showed similar results as previously reported with a freedom from autograft re-operation at 5, 10 and 12.5 years of 91.8  ±  1.4 %, 86.1  ±  2.0 %, and 86.1  ±  2.0 %, respectively.  The authors concluded that the Matrix P bioprosthesis used for the RVOT reconstruction in the Ross procedure showed unfavorable long-term echocardiographic results with a high rate of re-operation/re-intervention for structural pulmonary valve failure.  As a consequence, long-term survival of this patient cohort was impaired.  The authors concluded that based on these findings, the use of the Matrix P bioprosthesis for PVR for Ross procedures in adults should not be recommended.

The Florida Sleeve Valve-Sparing Procedure for the Treatment of Aortic Root Ectasia and Aneurysm

Aalaei-Andabili and associates (2019) stated that the Florida (FL) Sleeve procedure was introduced as a simplified approach for valve-sparing correction of functional type I aortic insufficiency (AI) associated with aortic root aneurysms.  In this study, these researchers examined the short- and long-term outcomes following the FL Sleeve procedure.  From May 2002 to January 2016, a total of 177 patients underwent the FL Sleeve procedure.  Left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left ventricular ejection fraction (LVEF), and degree of AI (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4) were evaluated by echocardiography.  Mean ± standard deviation of age was 49.41 ± 15.37 years.  Survival rate was 98 % at 1 year, 97 % at 5 years, and 93 % at 8 years.  Freedom from re-operation was 99 % at 1 year and 98 % at 2 to 8 years; 3 patients (1.69 %) died during hospitalization; 3 patients (1.69 %) developed peri-procedural stroke.  Post-operative follow-up echocardiography was available in 140 patients at 30 days, and 31 patients at 5 years.  AI grade significantly improved from baseline at 30 days (2.18 ± 1.26 versus 1.1 ± 0.93, p < 0.001) and at 5 years (2.0 ± 1.23 versus 1.45 ± 0.88, p = 0.04).  Pre-operative mean LVEDD significantly decreased from 52.20 ± 6.73 to 46.87 ± 8.40 (p < 0.001) at 30 days, and from 53.22 ± 7.07 to 46.61 ± 10.51 (p = 0.01) at 5 years.  The authors concluded that the FL Sleeve procedure was a safe, effective, and durable treatment of aortic root aneurysm and type I AI; long-term survival and freedom from re-operation rates were encouraging.

The authors stated that this study had several drawbacks.  First, this was a retrospective and single-center study.  Second, there were no comparison between outcomes of the FL Sleeve procedure and previous aortic valve-sparing (AVS) techniques.  Third, loss to follow-up of patients’ echocardiography measurements.

Wu and co-workers (2019) devised a simple modification of the FL Sleeve procedure to perform AVS surgery.  This technique was simple, quick, effective, and safe.  These researchers employed this technique in operations performed on 2 young patients with Marfan syndrome.  The initial and short-term results were satisfactory.  Moreover, these researchers stated that a larger number of cases and long-term follow-up are needed to prove its durability.

Tasca and colleagues (2020) noted that the Sleeve procedure is one of the options in patients with aortic root diseases and it might be suitable for patients with a bicuspid valve.  From October 2006 to December 2018, a total of 42 consecutive patients with bicuspid aortic valve and aortic root ectasia/aneurysm, with or without aortic regurgitation, were surgically treated with the Sleeve procedure.  In 20 patients (48 %) leaflets surgery was necessary and consisted of raphe mobilization/resection in 17 patients, plication of both leaflets in 2 patients and a 2-commissures re-suspension in 1 patient.  During a mean clinical follow-up time of 4.4 ± 3.1 years, the survival rate was 100 %, 1 patient required a re-operation at 6.1 years post-operatively, with an overall freedom from re-operation of 94 ± 5 %.  The rest of the patients (41/42), had no more than mild residual aortic valve regurgitation.  With a mean follow-up of 4.3 ± 1.7 years the magnetic resonance imaging (MRI) performed in 26 patients, did not show signs of aortic wall herniation through the key-holes or persisting creases of the aortic wall inside the prosthesis.  The authors concluded that patients with aortic root disease and bicuspid aortic valve may be treated with the Sleeve procedure with excellent mid-term results; however, a longer follow-up is needed before drawing any solid conclusion.

Furthermore, an UpToDate review on “Management of Marfan syndrome and related disorders” (Wright and Connolly, 2020) states that “Investigational approaches -- We agree with the 2015 Professional Advisory Statement from the Marfan Foundation that there are insufficient data on alternative approaches that reinforce rather than replace an aortic aneurysm (e.g., personalized external aortic root support [PEARS] procedure and "Florida sleeve" repair) to support a recommendation for clinical use at the present time.  Potential advantages include theoretically simpler technique and for PEARS, potential avoidance of use of cardiopulmonary bypass and minimizing the size of the surgical incision.  However, data on these procedures are limited to small numbers of patients at a small number of centers with limited durations of follow-up”.

Appendix

The pulmonary autograft procedure is contraindicated in individuals with the following conditions:

  • Extremes of age; or
  • Marfan's syndrome; or
  • Multiple pathology in which a second valve replacement device is needed; or
  • Multi-vessel coronary artery disease; or
  • Severely depressed left ventricular function.
Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:
33390 - 33391 Valvuloplasty, aortic valve, open, with cardiopulmonary bypass
33413 Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure)
33440 Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross- Konno procedure)

CPT codes not covered for indications listed in the CPB:

Florida Sleeve valve-sparing procedure - no specific code:

HCPCS codes not covered for indications listed in the CPB:

Decellularized Matrix P bioprosthesis - no specific code:

ICD-10 codes covered if selection criteria are met:
I06.0 Rheumatic aortic stenosis
I06.1 Rheumatic aortic insufficiency
I35.0 - I35.9 Nonrheumatic aortic valve disorders [not covered for individuals with bicuspid valves and aortic regurgitation or aortic dilation if other alternatives are available]
I71.00 - I71.9 Aortic aneurysm and dissection
I77.810 - I77.819 Aortic ectasia [aortic dilation]
Q23.0 Congenital stenosis of aortic valve
Q23.1 Congenital insufficiency of aortic valve
Q25.21 - Q25.4, Q25.8 - Q25.9 Other congenital malformations of aorta

The above policy is based on the following references:

  1. Aalaei-Andabili SH, Martin TD, Hess PJ, et al. The Florida Sleeve procedure is durable and improves aortic valve function. Aorta (Stamford). 2019;7(2):49-55.
  2. Al-Halees Z, Pieters F, Qadoura F, et al. The Ross procedure is the procedure of choice for congenital aortic valve disease. J Thorac Cardiovasc Surg. 2002;123(3):437-441; discussion 441-442.
  3. Alsoufi B, Al-Halees Z, Manlhiot C, et al. Mechanical valves versus the Ross procedure for aortic valve replacement in children: Propensity-adjusted comparison of long-term outcomes. J Thorac Cardiovasc Surg. 2009;137(2):362-370.
  4. Alsoufi B, Al-Halees Z, Manlhiot C, et al. Superior results following the Ross procedure in patients with congenital heart disease. J Heart Valve Dis. 2010;19(3):269-277; discussion 278.
  5. Ando Y, Ochiai Y, Tokunaga S, et al. Size and stiffness of the pulmonary autograft after the Ross procedure in children. Pediatr Cardiol. 2019;40(4):776-783.
  6. Bavaria JE, Desai N, Szeto WY, et al. Valve-sparing root reimplantation and leaflet repair in a bicuspid aortic valve: Comparison with the 3-cusp David procedure. J Thorac Cardiovasc Surg. 2015;149(2 Suppl):S22-S28.
  7. Benedetto U, Melina G, Takkenberg JJ, et al. Surgical management of aortic root disease in Marfan syndrome: A systematic review and meta-analysis. Heart. 2011;97(12):955-958.
  8. Briand M, Pibarot P, Dumesnil JG, et al. Midterm echocardiographic follow-up after Ross operation. Circulation. 2000;102(19 Suppl 3):III10-III14.
  9. Carrel T, Kadner A. Long-term clinical and imaging follow-up after reinforced pulmonary autograft Ross procedure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2016;19(1):59-62.
  10. Chambers JC, Somerville J, Stone S, Ross DN. Pulmonary autograft procedure for aortic valve disease. Circulation. 1997;96(7):2206-2214.
  11. Christ T, Paun AC, Grubitzsch H, et al. Long-term results after the Ross procedure with the decellularized AutoTissue Matrix P® bioprosthesis used for pulmonary valve replacement. Eur J Cardiothorac Surg. 2019;55(5):885-892.
  12. Concha M, Aranda PJ, Casares J, et al. Prospective evaluation of aortic valve replacement in young adults and middle-aged patients: Mechanical prosthesis versus pulmonary autograft. J Heart Valve Dis. 2005;14(1):40-46.
  13. Dalshaug DB, Caldarone CA, Camp P. Aortic valve disease and the Ross operation. eMedicine Pediatrics Topic 2823. Omaha, NE: eMedicine.com; updated July 18, 2003. Available at: http://www.emedicine.com/ped/topic2823.htm. Accessed June 24, 2004.
  14. David TE, Ivanov J, Armstrong S, et al. Aortic valve-sparing operations in patients with aneurysms of the aortic root ro ascending aortia. Ann Thorac Surg. 2002;74(5):S1758-S1761; discussion S1792-S1799.
  15. David TE, 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(1):68-73; discussion 73-75.
  16. David TE. Ross procedure at the crossroads. Circulation. 2009;119(2):207-209.
  17. El-Hamamsy I, Eryigit Z, Stevens LM, et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: A randomised controlled trial. Lancet. 2010;376(9740):524-531.
  18. Elkins RC, Knott-Craig CJ, Ward KE, Lane MM. The Ross operation in children: 10-year experience. Ann Thorac Surg. 1998;65(2):496-502.
  19. Elkins RC, Santangelo K, Stelzer P, et al. Pulmonary autograft replacement of the aortic valve: An evolution of technique. J Cardiac Surg. 1992;7(2):108-116.
  20. Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(41):2873-926.
  21. Erbel R, Alfonso F, Boileau C, et al; Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J. 2001;22(18):1642-1681.
  22. Esaki J, Leshnower BG, Binongo JN, et al. Clinical outcomes of the David V valve-sparing root replacement compared with bioprosthetic valve-conduits for aortic root aneurysms. Ann Thorac Surg. 2017;103(6):1824-1832.
  23. Etnel JRG, Grashuis P, Huygens SA, et al. The Ross procedure: A systematic review, meta-analysis, and microsimulation. Circ Cardiovasc Qual Outcomes. 2018;11(12):e004748.
  24. Forteza A, De Diego J, Centeno J, et al. Aortic valve-sparing in 37 patients with Marfan syndrome: Midterm results with David operation. Ann Thorac Surg. 2010;89(1):93-96.
  25. Gamba A, Tasca G, Giannico F, et al. Early and medium term results of the sleeve valve-sparing procedure for aortic root ectasia. Ann Thorac Surg. 2015;99(4):1228-1233.
  26. Hanke T, Stierle U, Boehm JO, et al; German Ross Registry. Autograft regurgitation and aortic root dimensions after the Ross procedure: The German Ross Registry experience. Circulation. 2007;116(11 Suppl):I251-I258.
  27. Hiratzka LF, Bakris GL, Beckman JA, et al.; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121(13):e266-e369.
  28. Hu R, Wang Z, Hu X, et al. Effect of native aortic valve sparing aortic root reconstruction surgery on short- and long-term prognosis in Marfan syndrome patients: A meta-analysis. Zhonghua Xin Xue Guan Bing Za Zhi. 2014;42(5):433-438.
  29. Hussain ST, Majdalany DS, Dunn A, et al. Early and mid-term results of autograft rescue by Ross reversal: A one-valve disease need not become a two-valve disease. J Thorac Cardiovasc Surg. 2018;155(2):562-572.
  30. Huygens SA, Etnel JRG, Hanif M, et al. Bioprosthetic aortic valve replacement in elderly patients: Meta-analysis and microsimulation. J Thorac Cardiovasc Surg. 2018 Oct 22 [Epub ahead of print].
  31. Jaggers J, Harrison JK, Bashore TM, et al. The Ross procedure: Shorter hospital stay, decreased morbidity, and cost effective. Ann Thorac Surg. 1998;65(6):1553-1557; discussion 1557-1558..
  32. Jamieson WRE, Cartier PC. Surgical management of valvular heart disease 2004. Canadian Cardiovascular Society Consensus Conference. Can J Cardiol. 2004;20(Suppl E):7E-120E.
  33. Jones TK, Lupinetti FM. Comparison of Ross procedures and aortic valve allografts in children. Ann Thorac Surg. 1998;66(Suppl 6):S170-S173.
  34. Joyce F, Tingleff J, Pettersson G. Expanding indications for the Ross operation. J Heart Valve Dis. 1995;4(4):352-363.
  35. Kabbani S, Jamil H, Nabhani F, et al. Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations. J Thorac Cardiovasc Surg. 2007;134(4):902-908.
  36. Kallenbach K, Baraki H, Khaladj N, et al. Aortic valve-sparing operation in Marfan syndrome: What do we know after a decade? Ann Thorac Surg. 2007;83(2):S764-S768; discussion S785-S790.
  37. Kallenbach K, Karck M, Pak D, et al. Decade of aortic valve sparing reimplantation: Are we pushing the limits too far? Circulation. 2005;112(9 Suppl):I253-I259.
  38. Karck M, Kallenbach K, Hagl C, et al. Aortic root surgery in Marfan syndrome: Comparison of aortic valve-sparing reimplantation versus composite grafting. J Thorac Cardiovasc Surg. 2004;127(2):391-398.
  39. Kari FA, Doll KN, Hemmer W, et al. Survival and freedom from aortic valve-related reoperation after valve-sparing aortic root replacement in 1015 patients. Interact Cardiovasc Thorac Surg. 2016;22(4):431-438.
  40. Kerendi F, Guyton RA, Vega JD, et al. Early results of valve-sparing aortic root replacement in high-risk clinical scenarios. Ann Thorac Surg. 2010;89(2):471-476; discussion 477-478.
  41. Kouchoukos NT, Davila-Roman VG, Spray TL, et al. 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):1-6.
  42. Kvitting JP, Kari FA, Fischbein MP, et al. David valve-sparing aortic root replacement: Equivalent mid-term outcome for different valve types with or without connective tissue disorder. J Thorac Cardiovasc Surg. 2013;145(1):117-126, 127.e1-e5; discussion 126-127.
  43. Laforest I, Dumesnil JG, Briand M, et al. Hemodynamic performance at rest and during exercise after aortic valve replacement: Comparison of pulmonary autografts versus aortic homografts. Circulation. 2002;106(12 Suppl 1):I57-I62.
  44. Legarra JJ, Concha M, Casares J, et al. Left ventricular remodeling after pulmonary autograft replacement of the aortic valve (Ross operation). J Heart Valve Dis. 2001;10(1):43-48.
  45. Leontyev S, Trommer C, Subramanian S, et al. The outcome after aortic valve-sparing (David) operation in 179 patients: A single-centre experience. Eur J Cardiothorac Surg. 2012;42(2):261-266; discussion 266-267.
  46. Linden PA, Cohn LH. Medium-term follow up of pulmonary autograft aortic valve replacement: Technical advances and echocardiographic follow up. J Heart Valve Dis. 2001;10(1):35-42.
  47. Liu L, Wang W, Wang X, et al. Reimplantation versus remodeling: A meta-analysis. J Card Surg. 2011;26(1):82-87.
  48. Loobuyck V, Soquet J, Moussa MD, et al. Active aortic endocarditis in young adults: Long-term results of the Ross procedure. Ann Thorac Surg. 2020 Feb 18 [Epub ahead of print].
  49. Luciani GB, Lucchese G, De Rita F, et al. Reparative surgery of the pulmonary autograft: Experience with Ross reoperations. Eur J Cardiothorac Surg. 2012;41(6):1309-1314; discussion 1314-1315.
  50. Malvindi PG, Cappai A, Basciu A, et al. David operation: Single center 10-year experience. J Cardiovasc Surg (Torino). 2015;56(4):639-645.
  51. Martin E, Laurin C, Jacques F, et al. More than 25 years of experience with the Ross procedure in children: A single-center experience. Ann Thorac Surg. 2019 Dec 24 [Epub ahead of print].
  52. Martin E, Mohammadi S, Jacques F, et al. Clinical outcomes following the Ross procedure in adults: A 25-year longitudinal study. J Am Coll Cardiol. 2017;70(15):1890-1899.
  53. Mastrobuoni S, Tamer S, de Kerchove L, El Khoury G. Valve sparing: Aortic root replacement with the reimplantation technique. Multimed Man Cardiothorac Surg. 2015;2015.
  54. Matsumori M, Tanaka H, Kawanishi Y, et al. Comparison of distensibility of the aortic root and cusp motion after aortic root replacement with two reimplantation techniques: Valsalva graft versus tube graft. Interact Cardiovasc Thorac Surg. 2007;6(2):177-181.
  55. Ono M, Goerler H, Kallenbach K, et al. Aortic valve-sparing reimplantation for dilatation of the ascending aorta and aortic regurgitation late after repair of congenital heart disease. J Thorac Cardiovasc Surg. 2007;133(4):876-879.
  56. Oswalt JD. Acceptance and versatility of the Ross procedure. Curr Opin Cardiol. 1999;14(2):90-94.
  57. Oury JH. Clinical aspects of the Ross procedure: Indications and contraindications. Semin Thorac Cardiovasc Surg. 1996;8(4):328-335.
  58. Pacini D, Settepani F, De Paulis R, et al. Early results of valve-sparing reimplantation procedure using the Valsalva conduit: A multicenter study. Ann Thorac Surg. 2006;82(3):865-871; discussion 871-872.
  59. Patel ND, Arnaoutakis GJ, George TJ, et al. Valve-sparing aortic root replacement in children: Intermediate-term results. Interact Cardiovasc Thorac Surg. 2011;12(3):415-419.
  60. Piccardo A, Ghez O, Gariboldi V, et al. Ross and Ross-Konno procedures in infants, children and adolescents: A 13-year experience. J Heart Valve Dis. 2009;18(1):76-82; discussion 83.
  61. Raja SG, Pollock JC. Current outcomes of Ross operation for pediatric and adolescent patients. J Heart Valve Dis. 2007;16(1):27-36.
  62. Raja SG, Pozzi M. Growth of pulmonary autograft after Ross operation in pediatric patients. Asian Cardiovasc Thorac Ann. 2004;12(4):285-290.
  63. Reddy VM, Rajasinghe HA, Teitel DF, et al. Aortoventriculoplasty with the pulmonary autograft: The 'Ross-Konno' procedure. J Thorac Cardiovasc Surg. 1996;111(1):158-167.
  64. Richardt D, Stierle U, Sievers HH. Long-term results after aortic valve-sparing-reimplantation operation (David) in bicuspid aortic valve. J Heart Valve Dis. 2015;24(1):4-9.
  65. Ross D, Jackson M, Davies J. The pulmonary autograft - a permanent aortic valve. Eur J Cardiothorac Surg. 1992;6(3)113-116; discussion 117.
  66. Roughneen PT, DeLeon SY, Eidem BW, et al. Semilunar valve switch procedure: Autotransplantation of the native aortic valve to the pulmonary position in the Ross procedure. Ann Thorac Surg. 1999;67(3):745-750.
  67. Rubay JE, Buche M, El Khoury GA, et al. The Ross operation: Mid-term results. Ann Thorac Surg. 1999;67(5):1355-1358.
  68. Saczkowski R, Malas T, Mesana T, et al. Aortic valve preservation and repair in acute Type A aortic dissection. Eur J Cardiothorac Surg. 2014;45(6):e220-226.
  69. Settepani F, Szeto WY, Pacini D, et al. Reimplantation valve-sparing aortic root replacement in Marfan syndrome using the Valsalva conduit: An intercontinental multicenter study. Ann Thorac Surg. 2007;83(2):S769-S773; discussion S785-S790.
  70. Shrestha M, Baraki H, Maeding I, et al. Long-term results after aortic valve-sparing operation (David I). Eur J Cardiothorac Surg. 2012;41(1):56-61; discussion 61-62.
  71. Stephens EH, Liang DH, Kvitting JP, et al.  Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement. J Thorac Cardiovasc Surg. 2014;147(1):169-177.
  72. Subramanian S, Leontyev S, Borger MA, et al. Valve-sparing root reconstruction does not compromise survival in acute type A aortic dissection. Ann Thorac Surg. 2012;94(4):1230-1234.
  73. Svensson LG, Adams DH, Bonow RO, et al. Aortic valve and ascending aorta guidelines for management and quality measures. Ann Thorac Surg. 2013;95(6 Suppl):S1-S66.
  74. Takkenberg JJ, Dossche KM, Hazekamp MG, et al. Report of the Dutch experience with the Ross procedure in 343 patients. Eur J Cardiothorac Surg. 2002;22(1):70-77.
  75. Takkenberg JJ, Klieverik LM, Schoof PH, et al. The Ross procedure: A systematic review and meta-analysis. Circulation. 2009;119(2):222-228.
  76. Tasca G, Trinca F, Riva B, et al. Sleeve valve-sparing procedure in bicuspid aortic valve. Early and midterm clinical results. J Cardiovasc Surg (Torino). 2020 Jan 23 [Epub ahead of print].
  77. Tran PK, Tsang VT, Cornejo PR, et al. Midterm results of the Ross procedure in children: An appraisal of the subannular implantation with interrupted sutures technique. Eur J Cardiothorac Surg. 2017;52(4):798-804.
  78. Um KJ, Mcclure GR, Belley-Cote EP, et al. Hemodynamic outcomes of the Ross procedure versus other aortic valve replacement: A systematic review and meta-analysis. J Cardiovasc Surg (Torino). 2018;59(3):462-470.
  79. Volguina IV, Miller DC, Lemaire SA, et al; Aortic Valve Operative Outcomes in Marfan Patients study group. Valve-sparing and valve-replacing techniques for aortic root replacement in patients with Marfan syndrome: Analysis of early outcome. J Thorac Cardiovasc Surg. 2009;137(3):641-649.
  80. Walters HL 3rd, Lobdell KW, Tantengco V, et al. The Ross procedure in children and young adults with congenital aortic valve disease. J Heart Valve Dis. 1997;6(4):335-342.
  81. Wang R, Ma WG, Tian LX, et al. Valve-sparing operation for aortic root aneurysm in patients with Marfan syndrome. Thorac Cardiovasc Surg. 2010;58(2):76-80.
  82. Wright MJ, Connolly HM. Management of Marfan syndrome and related disorders. UpToDate Inc., Waltham, MA. Last reviewed February 2020.
  83. Wu YS, Hsieh SR, Wang CC, Tsai CL. Modified Sleeve technique in aortic valve-sparing operation for Marfan syndrome. Ann Thorac Cardiovasc Surg. 2019;25(3):164-167.
  84. Zimmermann C, Attenhofer Jost C, Prêtre R, et al. Mid-term outcome of 100 consecutive Ross procedures: Excellent survival, but yet to be a cure. Pediatr Cardiol. 2018;39(3):595-603.