Key result
Ross procedure linked to ~58% lower mortality versus biological and mechanical AVR.
Why the study?
There has recently been renewed interest in the Ross procedure in adults, prompting a comparison of long-term outcomes versus biological and mechanical aortic valve replacement.
Does the Ross procedure improve survival compared to biological and mechanical AVR in young adults undergoing aortic valve surgery?
Cohort (n=1,302)
Yes
Does the Ross procedure improve survival compared to biological and mechanical AVR in young adults undergoing aortic valve surgery?
Hazard Ratio: 0.42 (95% CI 0.075–0.23)
p-value: p=0.003
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Not only was survival better than after biological or mechanical aortic valve replacement, it was also identical to the matched U.S. general population. To this day, this is the only operation that has ever been shown to restore survival after aortic valve replacement in young adults.”
“This is a huge deal because it demonstrates the impact of valve choice in the long term. However, there is an important word of caution: the Ross procedure is a more complex operation and should only be performed in Ross centers of excellence. When done in that setting, this represents a major breakthrough for young patients with aortic valve disease, including young women contemplating pregnancy.”
“The outcomes of the operation and the durability is highly dependent on the surgeon or the surgical team's experience, as well as their expertise.”
In young adults undergoing aortic valve surgery, the Ross procedure is associated with better long-term survival and fewer valve-related complications compared to prosthetic AVR.
BACKGROUND There has recently been renewed interest in the Ross procedure in adults. OBJECTIVES The goal of this study was to compare long-term outcomes after the Ross procedure vs biological and mechanical aortic valve replacement (AVR) in adults (aged 18-50 years) undergoing aortic valve surgery. METHODS Mandatory California and New York databases were queried between 1997 and 2014. Exclusion criteria included: ≥1 concomitant procedure, reoperations, infective endocarditis, intravenous drug use, hemodialysis, and out-of-state residency. Propensity matching (1:1:1) was used, resulting in 434 patients per group. The primary endpoint was all-cause mortality. Secondary endpoints were stroke, major bleeding, reoperation, and endocarditis. Median follow-up was 12.5 years (IQR: 9.3-15.7 years). RESULTS At 15 years, actuarial survival after the Ross procedure was 93.1% (95% CI: 89.1%-95.7%), similar to that of the age-, sex-, and race-matched U.S. general population. It was significantly lower after biological AVR (HR: 0.42; 95% CI: 0.23-0.075; P = 0.003) and mechanical AVR (HR: 0.45; 95% CI: 0.26-0.79; P = 0.006). At 15 years, the Ross procedure was associated with a lower cumulative risk of reintervention (P = 0.008) and endocarditis (P = 0.01) than biological AVR. In contrast, at 15 years, the Ross procedure was associated with a higher cumulative incidence of reoperation (P < 0.001) but lower risks of stroke (P = 0.03) and major bleeding (P = 0.016) than mechanical AVR. Thirty-day mortality after valve-related complications was lowest after a reintervention. CONCLUSIONS In young adults, the Ross procedure is associated with better long-term survival and freedom from valve-related complications compared with prosthetic AVR. This confirms the notion that a living valve substitute in the aortic position translates into improved clinically relevant outcomes.
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El-Hamamsy et al. (2022) conducted a cohort in aortic valve surgery (n=1,302). Ross procedure vs. biological and mechanical aortic valve replacement (AVR) was evaluated on all-cause mortality (HR 0.42, 95% CI 0.23-0.075, p=0.003). The Ross procedure was associated with better long-term survival compared with biological (HR 0.42; 95% CI 0.23-0.075; P=0.003) and mechanical AVR (HR 0.45; 95% CI 0.26-0.79; P=0.006).
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