Improving outcomes of right ventricular outflow tract reconstruction during the Ross operation: Homograft decellularization and surgical technique

Objectives

To evaluate the influence of decellularization and surgical technique in the cumulative incidence of homograft dysfunction and reinterventions after the Ross Operation.

Methods

From 1995 to 2024, 414 patients underwent a Ross operation using cryopreserved (n = 161, median follow-up = 20.4 years) or decellularized homografts (n = 253, median follow-up = 9.1 years). Thirty-nine patients receiving decellularized homografts had a proximal conical extension of the homograft with decellularized human pericardium. Homograft dysfunction was defined as a peak gradient ≥40 mm Hg or pulmonary insufficiency moderate or greater.

Results

The cumulative incidence of any dysfunction at 15 years was similar among the 2 groups (decellularized = 12.4%, vs cryopreserved = 11.2%). However, serial echocardiographic measurements revealed that peak gradients were lower in the decellularized homografts (β = −2.99, P < .001). Age and homograft size were risk factors for homograft stenosis in cryopreserved homografts, but only age was associated with this event in the decellularized cohort. The cumulative incidence of reoperations at 15 years was lower in the decellularized group (1.2% vs 6.8%). Conical extension improved hemodynamic performance of decellularized homografts even further and was associated with lower late peak gradients (β = −6.37 and β = −7.44, in relation to direct anastomosis and anterior hood, respectively).

Conclusions

This study represent the longest follow-up with decellularized homografts during the Ross Operation. Decellularized homografts were associated with slower progression of late gradients and lower cumulative incidence of reoperations up to 15 years of follow-up. Conical extension with decellularized human pericardium may further improve their early and late hemodynamic performance.