Evidence increasingly supports the Ross procedure for young adults

In recent years, the optimal technique for replacement of the aortic valve in young- and middle-aged patients has become increasingly controversial. Mechanical aortic valve replacement (AVR) had been the gold standard for many years, yet bioprosthetic valves have increasingly become the dominant choice [1]. This appears largely driven by a desire to avoid anticoagulation, as well as the availability of valve-in-valve transcatheter options. Most recently transcatheter valves have even been used in middle-aged patients, albeit still making up a small proportion of the overall cohort [1], and this trend is likely to accelerate in the coming years. The Ross procedure has enjoyed varying adoption over time, but many surgeons have remained concerned over technical complexity and the risk of reoperation on both aortic and pulmonary valves, and as such it remains under-utilized. This increased range of treatment choices for aortic valve replacement has further complicated decision-making for both clinicians and patients. Several propensity score-matched analyses comparing mechanical AVR and the Ross procedure [2–4] have been published in the last decade, of which only one has demonstrated a survival benefit for the Ross procedure [4]. In addition to these studies, a recent systematic review also demonstrated a survival benefit for the Ross procedure [5]. However, these studies mostly comprise single-centre reports, and the overall number of patients in these matched studies is low. In this context, we read with interest the article by Gofus et al. [6] in this issue of the Journal, which reports a propensity score-matched analysis of patients undergoing the Ross procedure from the Czech national registry of cardiac surgery. In total, there were 291 matched pairs who underwent aortic valve replacement between 2009 and 2020. They demonstrated improved survival following the Ross procedure compared to mechanical AVR. Furthermore, there was no significant difference in rates of valve-related reoperation between the 2 groups. Uniquely they reported data on early mortality and a large range of early morbidities, such as reoperation for bleeding, rates of blood transfusion, volume of mediastinal drainage and use of inotropes, all of which demonstrated no significant difference between the groups. These data have not been reported in other propensity-matched analyses and are important as, together with the low early mortality, demonstrate that the additional complexity of the Ross procedure does not increase early complications in experienced centres. These data should allay one of the greatest concerns of clinicians—that the long-term benefits of Ross procedure may come at the expense of higher early mortality and morbidity. The strengths of this study include the large number of pairs and multi-institutional nature of the study. It is important to keep in mind, however, that the study has relatively short follow-up (median 4 years for Ross and 6 years for mechanical AVR) and the difference in survival between the 2 groups is due to a small number of events. Nonetheless, this important study by Gofus et al. is a valuable contribution to the growing evidence of benefit for the Ross procedure compared to mechanical AVR in young- and middle-aged adults. It is increasingly apparent that the Ross procedure is associated with improved long-term survival without the cost of early morbidity and mortality. However, despite these potential benefits, the Ross procedure still constitutes <1% of aortic valve replacements in young- and middle-aged patients [1]. Furthermore, current international guidelines do not recommend the Ross procedure for young adults [7, 8]. We agree with the authors’ assertion that the Ross procedure warrants greater recognition in international guidelines on the management of aortic valve disease. However, increased awareness of the benefits of the Ross procedure needs to be combined with efforts to provide junior surgeons with training in the technical aspects of the operation, and the continued development of centres of excellence where adequate volumes of Ross procedures can be maintained. Together, we hope these endeavours will lead to better outcomes for young patients with aortic valve disease.