Comparison of the ross procedure with mechanical aortic valve replacement in patients aged 50 years and younger: a retrospective analysis of short- and long-term outcomes

Introduction. Aortic valve replacement (AVR) remains the only effective treatment method for severe symptomatic aortic valve disease; however, the choice of the optimal prosthesis for young patients continues to be debated. Mechanical prostheses, despite their durability, require lifelong anticoagulation, increasing the risk of complications and reducing quality of life, while the Ross procedure offers the prospect of long-term survival comparable to that of the general population. Aim: To compare the immediate and long-term outcomes of the Ross procedure and mechanical aortic valve replacemnet in patients aged 50 years and younger. Material and Methods. A retrospective analysis of 694 patients who underwent the Ross procedure or mechanical AVR at the Federal Center for Cardiovascular Surgery (Astrakhan, Russia) between 2009 and 2019 was performed. After applying inclusion criteria (age ≥ 18 years, prosthetic aortic valve replacement with a mechanical prosthesis or pulmonary autograft) and exclusion criteria (concomitant coronary artery bypass grafting (CABG), double-valve replacement, left ventricular ejection fraction ≤ 30%), 277 patients were selected and divided into two groups: Ross procedure ( n = 178) and mechanical AVR ( n = 99). The propensity score matching (PSM) method was used, forming two balanced groups of 66 patients each. Hospital mortality, complications, survival, freedom from reoperation, stroke, and combined endpoints were evaluated (mortality+stroke). Results. The median age in both groups was 44 years ( p = 0.993), with no significant differences in sex ( p = 0.324) or functional class of heart failure ( p = 0.598). Operative time, cardiopulmonary bypass time, and myocardial ischemia time were longer in the Ross group ( p < 0.001). Postoperative complications and hospital mortality did not differ, except for a higher rate of fresh frozen plasma transfusion in the Ross group (43.9% vs. 25.8%, p = 0.02). Peak and mean pressure gradients across the aortic valve were lower in the Ross group ( p < 0.001). One-year, three-year, five-year, and ten-year survival, freedom from cardiovascular mortality, and freedom from reoperation did not differ between groups ( p > 0.05). After PSM, differences in freedom from stroke and combined endpoints (mortality and stroke) were also eliminated ( p = 0.134 and p = 0.238, respectively). Conclusion. The Ross procedure and mechanical AVR demonstrate comparable short- and long-term outcomes in patients aged 50 years and younger. The Ross procedure is associated with better hemodynamic performance but requires longer operative times. Both methods can be effective treatment strategies, and the choice should be based on individual patient characteristics and surgical center expertise.