Key result
Ross procedure yields ~2% early adult mortality but carries high lifetime autograft and RVOT reintervention risk.
Why the study?
A comprehensive overview of outcomes after the Ross procedure was needed to support decision-making in aortic valve replacement in children and adults.
Does the Ross procedure improve life expectancy and clinical outcomes in children and adults requiring aortic valve replacement?
Meta-Analysis (n=13,129)
Does the Ross procedure improve life expectancy and clinical outcomes in children and adults requiring aortic valve replacement?
The Ross procedure provides excellent survival and near-normal life expectancy without the need for anticoagulation, though it carries a high lifetime risk of reintervention, particularly in children.
Microsimulation-derived lifetime risks after Ross procedure inform AVR decisions in children and adults; leaves open randomized comparisons with alternatives.
BACKGROUND: To support decision-making in aortic valve replacement in children and adults, we provide a comprehensive overview of outcome after the Ross procedure. METHODS AND RESULTS: A systematic search was conducted for publications reporting clinical outcome after the Ross procedure, published between January 1, 2000, and November 22, 2017. Reported event rates and time-to-event data were pooled and entered into a microsimulation model to calculate life expectancy and lifetime event risk. Ninety-nine publications were included (13 129 patients; total follow-up: 93 408 patient-years, pooled mean follow-up: 7.9±5.3 years). Pooled mean age at surgery was 9.4±5.5 years for children and 41.9±11.4 for adults. For children and adults, respectively, pooled early mortality risk was 4.19% (95% CI, 3.21-5.46) and 2.01% (95% CI, 1.44-2.82), late mortality rate was 0.54%/y (95% CI, 0.42-0.70) and 0.59%/y (95% CI, 0.46-0.76), autograft reintervention 1.28%/y (95% CI, 0.99-1.66) and 0.83%/y (95% CI, 0.68-1.01), and right ventricular outflow tract reintervention 1.97%/y (95% CI, 1.64-2.36) and 0.47%/y (95% CI, 0.37-0.59). Pooled thromboembolism and bleeding rates were low and comparable to the general population. Lifetime risks of autograft and right ventricular outflow tract reintervention were, respectively, 94% and 100% for children and 49% and 19% for a 45-year-old. Estimated life expectancy after surgery was 59 years for children (general population: 64 years) and 30 years for a 45 years old (general population: 31 years). CONCLUSIONS: Through excellent survival and avoidance of the burden of anticoagulation, the Ross procedure provides a unique opportunity for patients whose preferences do not align with the outcome provided by mechanical valve replacement and for growing children who also benefit from autograft diameter increase along with somatic growth. On the downside, almost all pediatric and many adult Ross patients will require a reintervention in their lifetime.
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Etnel et al. (2018) conducted a meta-analysis in Aortic valve replacement (n=13,129). Ross procedure was evaluated on Clinical outcomes including mortality and reintervention. The Ross procedure provides excellent survival, with early mortality of 4.19% in children and 2.01% in adults, though lifetime risks of autograft and RVOT reintervention are high.
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