Long-term outcomes of the Ross procedure in adults

Abstract

Background: The optimal aortic valve replacement for young and middle-aged adults remains elusive.Although several high-volume international centers and surgeons have demonstrated excellent long-term results with the pulmonary autograft (Ross procedure) in adult patients, current guidelines from the United States do not favor this technique. We evaluated long-term clinical and echocardiographic outcomes of adult patients undergoing the Ross procedure at our center.Methods: A retrospective review of 225 consecutive adult patients undergoing the Ross procedure was completed. Kaplan-Meier analysis was performed to evaluate overall survival, which was then compared to an age-and sex-matched general population with the log-rank test. Accounting for death as a competing hazard, the cumulative incidence of reintervention and autograft or homograft dysfunction were estimated over the long-term.Results: Mean age was 42±11 years, and 62 (28%) patients were at least 50 years old. A bicuspid aortic valve was present in 179 (80%) patients. The most common indications for surgery were aortic insufficiency (n=94, 43%), aortic stenosis (n=81, 36%), and mixed etiology (n=46, 21%). In-hospital mortality was 0.9%.Overall survival (with 95% confidence intervals) at 1-, 10-and 20-year was 97.8% (95.9-99.7%), 94.2% (91.0-97.4%), and 81.3% (74.8-88.3%), respectively. Overall survival approximated that of the general population (log-rank P=0.32). The cumulative incidence (with 95% confidence intervals) of any autograft or homograft reintervention at 10-, 15-, and 20-year was 16% (12-20%), 28% (21-35%), and 45% (36-54%), respectively. Conclusions:The Ross procedure restores a normal life expectancy to young and middle-aged adults with severe aortic valve disease. The need for reintervention increases steadily during the second decade after the Ross procedure, but less than half of patients require any reintervention for up to 20-year.

The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement

“…Long-term survival rates after the Ross procedure have also been encouraging. Long-term outcomes showed 10-year survival rates ranging from 81% to 94%, while 20-year survival rates ranged from 65% to 92% [26]. These results suggest that the Ross procedure can provide durable survival benefits for appropriately selected patients.…”

“…Ryan et al, 2021 n(225) [26] 20 Year Survival 81.3% (74.8-88.3%) Mortality (In-hospital) 0.9% (30 day) 2.2% Pergola et al, n(536) 2020 [18] 15 Year Freedom from all Re-operation 83% Freedom from Autograft reoperation 81% David et al, n(212) 2019 [23] 20 Year Mortality 10.8% Stelzer et al, n(702) 2021 [25] Perioperative Mortality 1% Aboud et al, n(2444) 2021 [28] 25 Year Survival 75.8% Early mortality 1%…”

Bicuspid Aortic Stenosis with and without Aortopathy: Considerations for Surgical Aortic Valve Replacement versus Transcatheter Aortic Valve Replacement

“…However, the PARTNER II trial used an earlier generation of balloonexpandable valves, and the PARTNER III trial noted less PVL but BAV patients were excluded. 6 The clinical significance of mild PVL is unclear but its impact may be increased in a younger patient who will have PVL for a longer period of time. An analysis of 17 studies and 181,433 patients found the risk for moderate to severe PVL to be higher in subjects with BAV than in those with tricuspid aortic valve (RR 1.42; 95% CI [1.29-1.58]; p<0.0001).…”

“…There are also data to suggest that the patient's life expectancy is restored to that of a matched group without aortic stenosis. 6 The use of SURD in BAV has been traditionally considered as contraindicated. However, this has been challenged, with multiple groups presenting data showing excellent results in BAV including Sievers type 0 valves.…”