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Peter D. Skillington - One of the best experts on this subject based on the ideXlab platform.
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pulmonary valve function late after Ross Procedure in 443 adult patients
The Annals of Thoracic Surgery, 2020Co-Authors: Tyson A Fricke, Edward Buratto, William Y. Shi, Rochelle Wynne, Marco Larobina, Peter D. Skillington, Leeanne E GriggAbstract:Background Limited data exist on long-term pulmonary valve function after the Ross Procedure. This study sought to determine the long-term function of the pulmonary valve in 443 consecutive adult patients who underwent a Ross Procedure. Methods All 443 patients who underwent a Ross Procedure between November 1992 and March 2018 were reviewed retrospectively. All underwent pulmonary valve replacement using a cryopreserved pulmonary allograft. Freedom from the study’s outcomes were calculated using Kaplan Meier survival. Risk factors for valve failure were analyzed using Cox regression. Results Mean age at time of operation was 39 years (range: 15-66 years). There was 1 (0.2%, 1 of 443) operative mortality. Nine patients required reintervention on the pulmonary allograft at a mean 6.1 years (range: 1-12 years) after Ross Procedure. Patients required pulmonary allograft reintervention for infective endocarditis (n = 4), severe pulmonary stenosis (n = 4), or severe pulmonary regurgitation (n = 1). Freedom from pulmonary allograft reintervention was 98.9% (95% confidence interval [CI] 97.1%-99.6%), 97.7% (95% CI 95.1%-98.9%), 96.6% (95% CI 93.3%-98.3%), and 96.6% (95% CI 93.3%-98.3%) at 5, 10, 15, and 20 years, respectively. Freedom from pulmonary allograft dysfunction (at least moderate pulmonary regurgitation and/or mean systolic gradient ≥ 25 mm Hg and/or reintervention) was 94.5% (95% CI 91.6%-96.4%), 88.1% (95% CI 83.6%-91.4%), 84.9% (95% CI 79.6%-88.9%), and 78.3% (95% CI 69.5%-84.9%) at 5, 10, 15, and 20 years, respectively. No risk factors were identified to influence pulmonary valve durability. Conclusions The pulmonary valve allograft gives excellent long-term function when used in adults undergoing the Ross Procedure. Reintervention on the pulmonary valve is rare and significant pulmonary allograft dysfunction is uncommon.
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Improved Survival After the Ross Procedure Compared With Mechanical Aortic Valve Replacement
Journal of the American College of Cardiology, 2018Co-Authors: Edward Buratto, William Y. Shi, Rochelle Wynne, Chin L. Poh, Marco Larobina, Michael O’keefe, John Goldblatt, James Tatoulis, Peter D. SkillingtonAbstract:Abstract Background It is unclear whether the Ross Procedure offers superior survival compared with mechanical aortic valve replacement (AVR). Objectives This study evaluated experience and compared long-term survival between the Ross Procedure and mechanical AVR. Methods Between 1992 and 2016, a total of 392 Ross Procedures were performed. These were compared with 1,928 isolated mechanical AVRs performed during the same time period as identified using the University of Melbourne and Australia and New Zealand Society of Cardiac and Thoracic Surgeons’ Cardiac Surgery Databases. Only patients between 18 and 65 years of age were included. Propensity-score matching was performed for risk adjustment. Results Ross Procedure patients were younger, and had fewer cardiovascular risk factors. The Ross Procedure was associated with longer cardiopulmonary bypass and aortic cRoss-clamp times. Thirty-day mortality was similar (Ross, 0.3%; mechanical, 0.8%; p = 0.5). Ross Procedure patients experienced superior unadjusted long-term survival at 20 years (Ross, 95%; mechanical, 68%; p Conclusions In this Australian, propensity-score matched study, the Ross Procedure was associated with better long-term survival compared with mechanical AVR. In younger patients, with a long life expectancy, the Ross Procedure should be considered in centers with sufficient expertise.
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Exercise hemodynamic performance of the pulmonary autograft following the Ross Procedure.
The Journal of heart valve disease, 1999Co-Authors: Peter D. Skillington, Andrew R. Bjorksten, John G. Morgan, Anthony G. Yapanis, Leeanne E GriggAbstract:BACKGROUND AND AIMS OF THE STUDY The Ross Procedure, in which the aortic valve is replaced with the patient's own pulmonary valve (pulmonary autograft), is considered an excellent alternative for younger patients requiring elective aortic valve replacement. Although resting pulmonary autograft hemodynamics are excellent, exercise hemodynamic data are lacking. The study aim was to measure the hemodynamic performance of the pulmonary autograft with exercise Doppler echocardiography (DE). METHODS Twenty-four Ross Procedure patients (20 males, four females; mean age 46 +/- 11 years) were studied at 25 +/- 14 months after aortic valve replacement with a pulmonary autograft. Patients had baseline supine DE to measure the maximum velocity (Vmax), and the peak and mean pressure gradient acRoss the pulmonary autograft. Effective orifice area was calculated from the continuity equation and indexed to body surface area (EOAi). Patients then underwent symptom-limited upright bicycle exercise with supine DE repeated immediately on stopping exercise. For comparison, 10 normal controls (age 41 +/-10 years) and five mechanical aortic valve patients (mean age 55 +/- 10 years) were studied. RESULTS At rest: Ross Procedure patients had similar Vmax (1.2 +/- 0.2 m/s), peak gradient (6 +/- 2 mmHg), mean gradient (4 +/- 1 mmHg) and EOAi (1.7 +/- 0.4 cm2/m2) to those of normal controls. Mechanical-valve patients had significantly higher Vmax (2.5 +/- 0.2 m/s, p
Ross M. Ungerleider - One of the best experts on this subject based on the ideXlab platform.
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Ross Procedure for patient with Marfan syndrome.
The Annals of thoracic surgery, 2014Co-Authors: Yoshio Ootaki, Michael J. Walsh, Irving Shen, Ross M. UngerleiderAbstract:The most prominent long-term complication after the Ross Procedure is the risk of autograft dilatation, and therefore its application in patients at increased perceived risk of autograft dilatation (those with bicuspid aortic valve disease, aortic insufficiency [AI] with dilated aorta, collagen vascular diseases such as Marfan syndrome) has been discouraged. We reported a modified Ross Procedure in 2005 in which the autograft was completely encased in a polyester graft before implantation to prevent further dilatation of the autograft. This case report describes follow-up of a patient with Marfan syndrome who underwent this modified Ross Procedure in July 2005.
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Modified Ross Procedure to prevent autograft dilatation.
The Annals of thoracic surgery, 2010Co-Authors: Ross M. Ungerleider, Yoshio Ootaki, Irving Shen, Karl F. WelkeAbstract:The most prominent, long-term complication after the Ross Procedure is autograft dilatation that can present within 1 to 2 years after the Ross operation. We describe a modified Ross Procedure in which the autograft is completely encased in a Dacron graft (Hemashield; Maquet Cardiovascular, Wayne, NJ) prior to implantation. We have performed 30 modified Ross Procedures since October 2004. There has been no mortality, and at follow-up none of the patients showed autograft dilatation. This article describes our current technique, which we believe is consistently reproducible and may be especially applicable to adults who are at risk for autograft dilatation after the Ross Procedure.
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Modification to the Ross Procedure to prevent autograft dilatation
Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual, 2005Co-Authors: Matthew Slater, Irving Shen, Karl F. Welke, Christopher Komanapalli, Ross M. UngerleiderAbstract:Dilatation of the pulmonary autograft is a problem described following Ross Procedure for aortic valve replacement. Patients at risk seem to be those with aortic insufficiency, bicuspid aortic valves, and those with aneurismal ascending aortas. We describe a technique for encasing the pulmonary autograft in a Dacron tube to prevent dilatation in these patients. This technique is reproducible and includes sewing the coronary arteries to all layers of the autograft and Dacron construct. Short-term follow-up shows excellent outcomes with respect to autograft valve function and lack of annular or sinotubular dilatation. This Procedure may be useful for extending the Ross Procedure to young adults, where autograft growth is no longer needed, to provide a non-dilatable neoaortic root.
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The Ross Procedure: Shorter Hospital Stay, Decreased Morbidity, and Cost Effective
The Annals of thoracic surgery, 1998Co-Authors: James Jaggers, Thomas M. Bashore, Robert D. Davis, Donald D. Glower, Ross M. UngerleiderAbstract:Abstract Background . The Ross Procedure has become an accepted and sometimes preferred alternative to mechanical aortic valve replacement. One criticism of the Ross Procedure is that it may have a higher operative mortality, morbidity, and cost. Several groups have shown that this operation can be performed safely with less than 3% mortality. The issue of higher cost has not been resolved. In this retrospective study we compared a consecutive group of patients undergoing the Ross Procedure with an age- and disease-matched group of patients who underwent mechanical aortic valve replacement. Methods . From 1993 to 1996, 22 consecutive adult patients (age range, 20 to 57 years; mean, 38 ± 14 years) underwent the Ross Procedure. Twenty-seven patients (age range, 17 to 57 years; mean, 41 ± 10 years) underwent mechanical aortic valve replacement between 1991 and 1996. The hospital cost (in 1996 dollars) and postoperative length of stay were calculated for each patient using Transition I, a hospital-wide cost accounting system. Results . There was no hospital mortality in either group. The incidence of significant valve-related complication was 5% (1/22 patients) in the Ross Procedure group and 22% (6/27 patients) in the mechanical valve group. There were two late deaths in the group with mechanical aortic valve replacement. The length of stay for the Ross Procedure group was 5.9 ± 2.1 days, versus 8 ± 1.85 days for the mechanical valve group ( p Conclusions . The data from this review demonstrate that the Ross Procedure can be done safely, with short hospital stays, decreased morbidity, and costs comparable with those of standard mechanical aortic valve replacement in patients with isolated aortic valve disease.
Leeanne E Grigg - One of the best experts on this subject based on the ideXlab platform.
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pulmonary valve function late after Ross Procedure in 443 adult patients
The Annals of Thoracic Surgery, 2020Co-Authors: Tyson A Fricke, Edward Buratto, William Y. Shi, Rochelle Wynne, Marco Larobina, Peter D. Skillington, Leeanne E GriggAbstract:Background Limited data exist on long-term pulmonary valve function after the Ross Procedure. This study sought to determine the long-term function of the pulmonary valve in 443 consecutive adult patients who underwent a Ross Procedure. Methods All 443 patients who underwent a Ross Procedure between November 1992 and March 2018 were reviewed retrospectively. All underwent pulmonary valve replacement using a cryopreserved pulmonary allograft. Freedom from the study’s outcomes were calculated using Kaplan Meier survival. Risk factors for valve failure were analyzed using Cox regression. Results Mean age at time of operation was 39 years (range: 15-66 years). There was 1 (0.2%, 1 of 443) operative mortality. Nine patients required reintervention on the pulmonary allograft at a mean 6.1 years (range: 1-12 years) after Ross Procedure. Patients required pulmonary allograft reintervention for infective endocarditis (n = 4), severe pulmonary stenosis (n = 4), or severe pulmonary regurgitation (n = 1). Freedom from pulmonary allograft reintervention was 98.9% (95% confidence interval [CI] 97.1%-99.6%), 97.7% (95% CI 95.1%-98.9%), 96.6% (95% CI 93.3%-98.3%), and 96.6% (95% CI 93.3%-98.3%) at 5, 10, 15, and 20 years, respectively. Freedom from pulmonary allograft dysfunction (at least moderate pulmonary regurgitation and/or mean systolic gradient ≥ 25 mm Hg and/or reintervention) was 94.5% (95% CI 91.6%-96.4%), 88.1% (95% CI 83.6%-91.4%), 84.9% (95% CI 79.6%-88.9%), and 78.3% (95% CI 69.5%-84.9%) at 5, 10, 15, and 20 years, respectively. No risk factors were identified to influence pulmonary valve durability. Conclusions The pulmonary valve allograft gives excellent long-term function when used in adults undergoing the Ross Procedure. Reintervention on the pulmonary valve is rare and significant pulmonary allograft dysfunction is uncommon.
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Exercise hemodynamic performance of the pulmonary autograft following the Ross Procedure.
The Journal of heart valve disease, 1999Co-Authors: Peter D. Skillington, Andrew R. Bjorksten, John G. Morgan, Anthony G. Yapanis, Leeanne E GriggAbstract:BACKGROUND AND AIMS OF THE STUDY The Ross Procedure, in which the aortic valve is replaced with the patient's own pulmonary valve (pulmonary autograft), is considered an excellent alternative for younger patients requiring elective aortic valve replacement. Although resting pulmonary autograft hemodynamics are excellent, exercise hemodynamic data are lacking. The study aim was to measure the hemodynamic performance of the pulmonary autograft with exercise Doppler echocardiography (DE). METHODS Twenty-four Ross Procedure patients (20 males, four females; mean age 46 +/- 11 years) were studied at 25 +/- 14 months after aortic valve replacement with a pulmonary autograft. Patients had baseline supine DE to measure the maximum velocity (Vmax), and the peak and mean pressure gradient acRoss the pulmonary autograft. Effective orifice area was calculated from the continuity equation and indexed to body surface area (EOAi). Patients then underwent symptom-limited upright bicycle exercise with supine DE repeated immediately on stopping exercise. For comparison, 10 normal controls (age 41 +/-10 years) and five mechanical aortic valve patients (mean age 55 +/- 10 years) were studied. RESULTS At rest: Ross Procedure patients had similar Vmax (1.2 +/- 0.2 m/s), peak gradient (6 +/- 2 mmHg), mean gradient (4 +/- 1 mmHg) and EOAi (1.7 +/- 0.4 cm2/m2) to those of normal controls. Mechanical-valve patients had significantly higher Vmax (2.5 +/- 0.2 m/s, p
Tirone E. David - One of the best experts on this subject based on the ideXlab platform.
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Ross Procedure in Adults for Cardiologists and Cardiac Surgeons: JACC State-of-the-Art Review
Journal of the American College of Cardiology, 2018Co-Authors: Amine Mazine, Ismail El-hamamsy, Tirone E. David, Magdi H. Yacoub, Subodh Verma, Mark D. Peterson, Robert O. Bonow, Deepak L. BhattAbstract:The ideal aortic valve substitute for young and middle-aged adults remains elusive. The Ross Procedure (pulmonary autograft replacement) is the only operation that allows replacement of the diseased aortic valve with a living substitute. However, use of this Procedure has declined significantly due to concerns over increased surgical risk and potential long-term failure of the operation. Several recent publications from expert centers have shown that in the current era, the Ross Procedure can be performed safely and reproducibly in appropriately selected patients. Furthermore, an increasing body of evidence suggests that the Ross Procedure is associated with better long-term outcomes compared with conventional aortic valve replacement in young and middle-aged adults. In this paper, the authors review the indications and technical considerations of the Ross Procedure, describe its advantages and drawbacks, and discuss patient selection criteria. Finally, the authors provide a comprehensive synthesis of the current Ross published reports to enable cardiologists and surgeons to make appropriate decisions for their patients with aortic valve disease.
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Late results of the Ross Procedure.
The Journal of thoracic and cardiovascular surgery, 2018Co-Authors: Tirone E. David, Maral Ouzounian, Carolyn M. David, Myriam Lafreniere-roula, Cedric ManlhiotAbstract:Abstract Objective The study objective was to examine the long-term results of the Ross Procedure in a cohort of patients followed prospectively for more than 2 decades. Methods From 1990 to 2004, 212 consecutive patients with a median age (interquartile range) of 34 years (28-41) underwent the Ross Procedure; 82% had congenital aortic valve disease. The technique of aortic root replacement was used in one half of the patients. Patients have been followed prospectively for a median (interquartile range) of 18.0 (14.6-21.2) years. Valve function was assessed by echocardiography. Results Cumulative mortality at 20 years was 10.8% (95% confidence interval, 6.5-17.8). Thirty patients required Ross-related reoperations and 3 for coronary artery disease. The cumulative probability of Ross-related reoperations at 20 years was 16.8% (95% confidence interval, 11.3-24.5), on the pulmonary autograft was 11.5% (95% confidence interval, 7.2-18.0), and on the pulmonary homograft was 8.2% (4.6-14.7). The implantation technique was not associated with the cumulative incidence of reoperations on the pulmonary autograft. The development of moderate or severe aortic insufficiency and pulmonary homograft dysfunction increased with time. At 20 years, the probability of aortic insufficiency was 13% (95% confidence interval, 8.0-20.3) and of pulmonary homograft dysfunction was 19.7% (95% confidence interval, 13.9-27.2). Preoperative aortic insufficiency was associated with increased odds of postoperative aortic insufficiency. Conclusions The long-term results of the Ross Procedure are excellent regardless of the implantation technique, but there is a progressive deterioration of function of both semilunar valves.
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Reoperations After the Ross Procedure
Circulation, 2010Co-Authors: Tirone E. DavidAbstract:Article see p 1153 There is no perfect heart valve substitute, and the Ross Procedure to treat aortic valve disease is no exception. In this issue of Circulation , Stulak and associates from the Mayo Clinic give a detailed account of the outcomes of reoperations on 56 patients who had the Ross Procedure.1 The authors concluded that “a broad spectrum of complex reoperations may be required after the Ross Procedure,” and that “patients and family members considering the Procedure should be informed of the potential for associated morbidity should reoperation be necessary.” The reality, however, is that the Ross Procedure is a complex operation, and one should not be surprised that reoperations are more complicated. The authors emphasized that 144 Procedures were needed in those 56 patients. However, considering that the Ross Procedure involves two heart valves and possibly the neoaortic root and the coronary arteries if the technique of aortic root replacement was used at the initial operation, one should not be surprised about the number of Procedures at reoperations. Nevertheless, among those 144 Procedures, the authors included enlargement of the pulmonary (28 patients) and aortic annulus (4 four patients) as additional operations when they are really part of valve replacement. Other Procedures, such as replacement of the ascending aorta for aneurysm, mitral valve surgery, and atrial septal defect (19 patients total) have more to do with the patients' cardiovascular pathology than the fact that they had a previous Ross Procedure. In spite of these complex and extensive reoperative Procedures, only one patient died–a remarkably low operative mortality of only 1.8%. However, it is worrisome that within a median follow-up of only 8 months there were 4 additional deaths. Thus, one can estimate 1-year survival of approximately 90%, which is low for …
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Ross Procedure at the CRossroads
Circulation, 2009Co-Authors: Tirone E. DavidAbstract:The quest for a perfect heart valve substitute has been going on for half a century. In 1960, Lower et al1 described the feasibility of replacing the aortic valve of dogs with the native pulmonary valve. In 1967, Ross performed this Procedure in humans.2 Ross transferred the pulmonary valve into the aortic root with the same technique used to implant aortic valve homograft3 (ie, the pulmonary sinuses of the pulmonary root were partially excised, and the pulmonary valve was secured in the recipient’s aortic root with 2 suture lines, 1 below and 1 above the aortic annulus, leaving the coronary artery orifices unobstructed). Although many surgeons gained experience with this type of aortic valve replacement using an aortic valve homograft, the Ross Procedure did not gain widespread popularity until the late 1980s when the technique of aortic root replacement was described for this operation.4 In this approach, the aortic root is excised, the pulmonary root is sutured to the aortic annulus and ascending aorta, and the coronary arteries are reimplanted into the neoaortic root. This technique made the early outcomes more predictable than when the subcoronary technique was used, and enthusiasm for the Ross Procedure increased during the 1990s. A voluntary international registry was developed, and thousands of patients were entered into that registry,5 but there have been no reports on long-term results. In the year 2000, we reported that the pulmonary autograft dilated and that the dilation was often accompanied by aortic insufficiency (AI) when the pulmonary autograft was used as a freestanding neoaortic root, whereas the techniques of subcoronary implantation and aortic root inclusion (pulmonary root inside of the aortic root) prevented dilation during a mean follow-up of 44 months.6 Other investigators confirmed our findings of dilation of the pulmonary autograft and …
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Mid-term results of the Ross Procedure.
Journal of cardiac surgery, 2001Co-Authors: Domenico Paparella, Tirone E. David, Susan Armstrong, Joan IvanovAbstract:Although the Ross Procedure has been performed for over three decades, its role in the management of patients with aortic valve disease is not well established. This study reviews our experience with this operation. From 1990 to 1999, 155 patients underwent the Ross Procedure. The mean age of 106 men and 49 women was 35 years. Most patients (85%) had congenital aortic valve disease. The pulmonary autograft was implanted in the subcoronary position in 2 patients, as an aortic root inclusion in 78, and aortic root replacement in 75. The follow-up extended from 9 to 114 months, mean of 45 +/- 28 months, and it was complete. All patients have had Doppler echocardiographic studies. There was only one operative and one late death. The survival was 98% at 7 years. The freedom from 3+ or 4+ aortic insufficiency was 86% at 7 years and the freedom from reoperation on the pulmonary autograft was 95% at 7 years. Dilation of the aortic annulus and/or sinotubular junction was the most common cause of aortic insufficiency. One patient required three reoperations on the biological pulmonary valve. Most patients (96%) have no cardiac symptoms. The Ross Procedure has provided excellent functional results in most patients, but progressive aortic insufficiency due to dilation of the aortic annulus and/or sinotubular junction is a potential problem in a number of patients.
Rochelle Wynne - One of the best experts on this subject based on the ideXlab platform.
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pulmonary valve function late after Ross Procedure in 443 adult patients
The Annals of Thoracic Surgery, 2020Co-Authors: Tyson A Fricke, Edward Buratto, William Y. Shi, Rochelle Wynne, Marco Larobina, Peter D. Skillington, Leeanne E GriggAbstract:Background Limited data exist on long-term pulmonary valve function after the Ross Procedure. This study sought to determine the long-term function of the pulmonary valve in 443 consecutive adult patients who underwent a Ross Procedure. Methods All 443 patients who underwent a Ross Procedure between November 1992 and March 2018 were reviewed retrospectively. All underwent pulmonary valve replacement using a cryopreserved pulmonary allograft. Freedom from the study’s outcomes were calculated using Kaplan Meier survival. Risk factors for valve failure were analyzed using Cox regression. Results Mean age at time of operation was 39 years (range: 15-66 years). There was 1 (0.2%, 1 of 443) operative mortality. Nine patients required reintervention on the pulmonary allograft at a mean 6.1 years (range: 1-12 years) after Ross Procedure. Patients required pulmonary allograft reintervention for infective endocarditis (n = 4), severe pulmonary stenosis (n = 4), or severe pulmonary regurgitation (n = 1). Freedom from pulmonary allograft reintervention was 98.9% (95% confidence interval [CI] 97.1%-99.6%), 97.7% (95% CI 95.1%-98.9%), 96.6% (95% CI 93.3%-98.3%), and 96.6% (95% CI 93.3%-98.3%) at 5, 10, 15, and 20 years, respectively. Freedom from pulmonary allograft dysfunction (at least moderate pulmonary regurgitation and/or mean systolic gradient ≥ 25 mm Hg and/or reintervention) was 94.5% (95% CI 91.6%-96.4%), 88.1% (95% CI 83.6%-91.4%), 84.9% (95% CI 79.6%-88.9%), and 78.3% (95% CI 69.5%-84.9%) at 5, 10, 15, and 20 years, respectively. No risk factors were identified to influence pulmonary valve durability. Conclusions The pulmonary valve allograft gives excellent long-term function when used in adults undergoing the Ross Procedure. Reintervention on the pulmonary valve is rare and significant pulmonary allograft dysfunction is uncommon.
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Improved Survival After the Ross Procedure Compared With Mechanical Aortic Valve Replacement
Journal of the American College of Cardiology, 2018Co-Authors: Edward Buratto, William Y. Shi, Rochelle Wynne, Chin L. Poh, Marco Larobina, Michael O’keefe, John Goldblatt, James Tatoulis, Peter D. SkillingtonAbstract:Abstract Background It is unclear whether the Ross Procedure offers superior survival compared with mechanical aortic valve replacement (AVR). Objectives This study evaluated experience and compared long-term survival between the Ross Procedure and mechanical AVR. Methods Between 1992 and 2016, a total of 392 Ross Procedures were performed. These were compared with 1,928 isolated mechanical AVRs performed during the same time period as identified using the University of Melbourne and Australia and New Zealand Society of Cardiac and Thoracic Surgeons’ Cardiac Surgery Databases. Only patients between 18 and 65 years of age were included. Propensity-score matching was performed for risk adjustment. Results Ross Procedure patients were younger, and had fewer cardiovascular risk factors. The Ross Procedure was associated with longer cardiopulmonary bypass and aortic cRoss-clamp times. Thirty-day mortality was similar (Ross, 0.3%; mechanical, 0.8%; p = 0.5). Ross Procedure patients experienced superior unadjusted long-term survival at 20 years (Ross, 95%; mechanical, 68%; p Conclusions In this Australian, propensity-score matched study, the Ross Procedure was associated with better long-term survival compared with mechanical AVR. In younger patients, with a long life expectancy, the Ross Procedure should be considered in centers with sufficient expertise.
