Ross and Yasui operations for complex biventricular repair in infants with critical left ventricular outflow tract obstruction

Objective: To define the outcomes following Ross and Yasui procedures for complex biventricular repair of critical left ventricular outflow tract obstruction (LVOTO). Methods: Of 1217 neonates presenting with critical LVOTO enrolled in the Congenital Heart Surgeons Society studies (19942008), 52 underwent the Ross or Yasui procedure and their outcomes were investigated using univariate and multivariable parametric models. Results: ROSS (N = 39): The Ross procedure (median age 87 days) was rarely the primary intervention (5/39, 13%). A significant number of cases were performed to treat iatrogenic aortic regurgitation after other previous interventions (25/39, 64%). Co-existing functional morphological defects were also common: 72% had preoperative evidence of mitral dysfunction, moderate-to-severe left ventricular dysfunction or endocardial fibroelastosis. Emergency iatrogenic aortic regurgitation (P = 0.005) and co-existing abnormalities (mitral stenosis, P = 0.02; mitral regurgitation, P = 0.05; LV dysfunction, P = 0.03) were strong determinants of death. Severe postoperative ventricular dysfunction or need for extracorporeal membrane oxygenation (ECMO) conferred negligible survival. Younger age was associated with disproportionately worse late outcome (5-year survival 44 +/- 10% for neonates vs 76 +/- 8% for age >3 months, P=0.0013). However, mitral and left ventricular dysfunction and emergency presentation were significantly more common in the younger age groups. Infants less than 3 months of age without co-existing abnormalities had acceptable late survival ( 75 +/- 20%). YASUI (N = 13): Yasui repair (median age 22 days) was usually the primary intervention (nine of 13) but occasionally followed Norwood palliation (four of 13). None was an emergency. All had a ventricular septal defect. Survival was 69 +/- 13% at 10 years, which is not significantly different from other biventricular repair strategies in neonates. Aortic atresia was associated with better survival than stenosis (90 +/- 12% vs 30 +/- 14% at 3 years, P = 0.039). None reverted to univentricular physiology later. Conclusions: Case selection is key for complex biventricular repair and the importance of appropriate case selection is exaggerated at young ages. All available options should be considered before pursuing the Ross operation in the presence of co-existing functional morphological abnormalities or emergent iatrogenic aortic regurgitation. However, both the Ross and Yasui operations in children (including neonates and young infants) with favourable functional morphology offer good survival, at least matching that of other biventricular repair strategies. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.