Role of the ross procedure and stentless biological prostheses in acute aortic valve endocarditis

OBJECTIVES Infective endocarditis (IE) is associated with high morbidity and mortality; nearly 40% present with isolated aortic valve (AV) endocarditis. No detailed guidelines on surgical strategies are currently available particularly for younger patients. The aim of this study was to compare mid-term results of conventional valve(AVR) and root replacement and the Ross procedure in patients < 60 years. METHODS Between 1997 and 2023, 176patients >18 and <60 years underwent surgery for AV IE. Patients with AV repair (n = 44) were excluded; the remaining 132 (male 82%; mean age 46 ± 11 years) underwent a Ross procedure(n = 32),mechanical AVR(n = 28), biological AVR(n = 72). Median and mean follow-up were 6.4[IQR 2.1–12.9]years and 7.9 ± 6.6 years(1041patient-years). RESULTS Twenty-seven patients(20%; Ross n = 1, biological AVR n = 20, mechanical AVR n = 6; p = 0.033) required permanent pacemaker implantation , 15patients had recurrent endocarditis(11%; Ross n = 1, biological AVR n = 11, mechanical AVR n = 3; p = 0.028). Survival was 78% at 15 years (Ross 92%; biological AVR 72%; mechanical AVR 70%; p = 0.176). At 15 years, it was 79% after native valve and 73% after prosthetic valve IE (p = 0.622), and 66% after biological AVR and 93% after root replacement (p = 0.05). At 15 years, freedom from AV reoperation was 72%(Ross 73%; biological stented AVR 58%; biological stentless root replacement 76%; mechanical AVR 82%; p = 0.453). CONCLUSIONS Long-term survival was good after the Ross procedure and stentless biological valves but was best after the Ross procedure with the lowest valve-related complications. Reoperation was non-negligible but similar between the Ross procedure and stentless biological root. Abscess exclusion with a patch and subsequent valve replacement was associated with inferior results. The Ross procedure offers the best potential for true long-term durability. In patients >50 years, stentless biological root replacement may be an alternative.