Hemodynamic performance during maximum exercise in adult patients with the Ross operation and comparison with normal controls and patients with aortic bioprostheses

This study examines the resting and exercise hemodynamic performance of the pulmonary autografts in the aortic position as well as of the homografts used for right ventricular outflow reconstruction in patients undergoing the Ross operation. Previous studies have reported excellent resting hemodynamics in patients who underwent aortic valve replacement with a pulmonary autograft. However, there are very few studies of their hemodynamic performance during exercise. Twenty adult subjects who underwent the Ross operation and 12 normal control subjects were submitted to maximum ramp bicycle exercise. The valve effective orifice areas and transvalvular gradients of both aortic (autograft) and pulmonary (homograft) valves were measured at rest and at peak of maximum exercise using Doppler echocardiography. Valve areas were indexed for body surface area. The hemodynamics of the aortic valve were very similar in Ross subjects and in control subjects at rest and during exercise. However, the indexed valve area of the pulmonary valve at rest was significantly (p <0.001) lower in the Ross subjects (1.10 ± 0.46 cm2/m2) than in the control subjects (1.95 ± 0.41 cm2/m2), resulting in higher (p = 0.004) mean gradients at rest (Ross: 9 ± 7 mm Hg vs control: 2 ± 1 mm Hg) and at peak exercise (Ross: 21 ± 14 mm Hg vs control: 7 ± 2 mm Hg). The pulmonary autograft provided excellent hemodynamics in the aortic position either at rest or during maximum exercise, whereas moderately high gradients were found during exercise across the homograft implanted in the pulmonary valve position. Future improvement of the Ross procedure should be oriented toward the search of new methods to prevent the deterioration of the homografts.