Autograft Reinforcement in the Ross Procedure: A Systematic Review and Patient-level Meta-Analysis.

The Ross procedure is a well-established option for aortic valve replacement, although progressive autograft dilation remains a significant long-term complication. While several reinforcement techniques have been proposed to address this issue, their effectiveness has yet to be rigorously evaluated. A PRISMA-compliant search was conducted for studies involving reinforced (RR) and non-reinforced (NR) Ross procedures. Meta-analysis with individual patient data (IPD) assessed survival and freedom-from-autograft reoperation rates. Subgroup analyses were conducted for the various reinforcement methods. Sixteen cohort studies comprising 2,514 reinforced Ross (RR) and 595 non-reinforced (NR) patients were included. Pre- and peri-operative characteristics were comparable between groups. Individual patient data analysis of comparative studies demonstrated superior survival in the RR group, with 5-, 10-, and 15-year survival rates of 100%, 98.8%, and 98.8%, respectively, compared to 95.0%, 93.7%, and 82.6% in the NR group (HR: 11.9, p=0.016). Similarly, freedom from autograft reoperation at 5, 10, and 15 years was 96.4%, 94.2%, and 86.6% in the RR group versus 95.8%, 87.6%, and 77.7% in the NR group (HR: 2.06, p<0.001). Subgroup analysis showed comparable outcomes across different reinforcement techniques. Reinforced Ross procedures are associated with improved survival and freedom-from-autograft reoperation rates compared to unsupported pulmonary autografts.