Table 1.

Strengths and Limitations of the Techniques Used to Prevent Pulmonary Autograft Dilatation.

Technique	Strengths	Limitations
External support within a Dacron tube	• Good midterm stability of the neo-sinus diameters	• Might lead to autograft distortion • Risk of early aortic regurgitation • Coronaries can be distorted by the Dacron graft • Limits the natural movements of the autograft • Dacron can cause an inflammatory reaction with the pulmonary autograft • Use of foreign material • Excess stress on aortic valve cusps from rigid external support
PEARS	• Does not seem to cause an inflammatory response with the autograft • Prevents dilatation of aneurysms in patients with Marfan syndrome • Prevents dilatation in an animal model of the Ross procedure	• Might limit the natural movements of the autograft • Sizing of the PEARS might be troublesome knowing that the ideal geometry of the pulmonary autograft in the aortic position is not clearly defined • Excess stress on aortic valve cusps from rigid external support
Autologous support (inclusion technique)	• Excellent long-term follow-up • Effectively prevents pulmonary autograft dilatation • Low risk of endocarditis • Reinforcement with compliant structure minimizes stress on valve cusps	• Might limit the natural movements of the autograft • Challenging to apply to patients with unicuspid and type 0 bicuspid valves or coronary malposition • Might induce distortion of the autograft in patients with large size discrepancies between the aortic root and pulmonary autograft
Resorbable scaffold	• Has the potential to combine the advantages of external support and excellent hemodynamics • Prevents dilatation in an animal model	• Has not been tested in humans yet • Coronary anastomosis might be challenging when implanted in the aortic root position • Potential inflammatory reaction during resorption with unpredictable consequences
Tailored approach to prevent pulmonary autograft dilatation	• Maintains the natural elastic recoil of native tissue • Good midterm stability of the neo-sinus diameter	• Adequate blood pressure control might be difficult to achieve with some patients
Subcoronary implantation	• Keeps the native aortic wall • Lower risk of dilatation for most patients • No coronary anastomoses	• Can be technically challenging, especially in smaller annulus • Risk of early failure due to autograft distortion • Potential for early failure in cases of mismatch between the size of the pulmonary and aortic annuli • Coronary malposition limits generalizability to all anatomic variants

Abbreviation: PEARS, personalized external aortic root support.