Black Patients Experience Higher Complication Burden and Distinct Valve Selection Patterns in Aortic Valve Replacement

Background Young adults undergoing the Ross procedure for aortic valve replacement may have better outcomes than more conventional mechanical and bioprosthetic aortic valve replacement. This study evaluates racial disparities in access to the Ross procedure and postoperative outcomes, hypothesizing that Black patients may have differing Ross utilization due to constrained valve options, with persistent disparities in postoperative complications. Methods Cases of open aortic valve replacement (AVR) surgery between 2012 and 2021 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were isolated, with all transcatheter aortic valve replacement (TAVR) cases excluded. All data was deidentified with IRB exemption. Univariate analysis and propensity score matching with binary logistic regression were performed to assess the independent effect of black self-identified race on access and 30-day post-operative complications. Covariates included in the propensity models included age, gender, BMI, smoking status, as well as comorbidities including diabetes, congestive heart failure, kidney failure, and chronic obstructive pulmonary disease. Results Among 5,698 isolated AVR cases in ACS-NSQIP, most were White patients (93.7%), older (median age 71), and underwent mechanical AVR, with Ross procedures remaining rare at 260 (4.6%) cases. Black patients were less likely to receive mechanical AVR overall, but among those younger than 60, were more likely than White patients to undergo the Ross procedure. Across valve types, Black patients experienced higher rates of postoperative patient complications, including acute renal failure, prolonged mechanical ventilation, reintubation, cardiac arrest and 30-day mortality. An adjusted analysis demonstrated that Black race was an independent predictor of severe postoperative complications regardless of valve strategy. Conclusions Differences in AVR use and outcomes between Black and White patients reflect structural, socioeconomic, and clinical factors rather than biology. Higher Ross use among younger Black patients likely reflects greater comorbidity and limited valve options, while persistently worse outcomes highlight the impact of baseline risk and systemic inequities. Addressing these disparities requires research incorporating socioeconomic and care-delivery factors, alongside clinical strategies such as standardized referrals, preoperative optimization, and equity-focused decision support.