Association of Adult and Pediatric Cardiac Surgery Volumes with Outcomes of the Ross Procedure in Adults

BACKGROUND: There is growing interest in application of the Ross procedure for treatment of aortic valve disease; however, utilization is restricted to specialized centers. The present study evaluated the differential association of adult aortic valve surgery and pediatric cardiac surgery volumes on outcomes of adults undergoing the Ross operation. METHODS: The 2016-2022 Nationwide Readmissions Database was queried to identify all adults undergoing the Ross procedure. Hospitals were categorized as pediatric high-volume centers (pHVC, ≥75th percentile pediatric cardiac surgery volume), adult high-volume centers (aHVC, ≥75th percentile aortic valve replacement/repair volume among non-pHVC), and low-volume centers (LVC). Major adverse events (MAE) were defined as a composite of mortality, stroke, prolonged ventilation, acute renal failure, pulmonary embolism, cardiac arrest, and reoperation. RESULTS: Among 1,212 adults undergoing the Ross operation, 37.7% were treated at pHVC, 56.7% at aHVC, and 5.6% at LVC. National utilization increased from 63 cases in 2016 to 385 in 2022, with the number of performing centers rising from 14 to 37. Patients at LVC experienced the highest rates of MAE (42.1% vs aHVC 8.8% vs pHVC 3.8%, p<0.001). After risk adjustment, care at LVC was associated with a 7.7-fold increase in odds of MAE compared to pHVC (95% CI 3.0-19.7, p<0.001). Outcomes at aHVC and pHVC were comparable, although aHVC had higher rates of reoperation (4.5% vs 0.6%, p<0.001). CONCLUSIONS: Adults undergoing the Ross operation at LVC face worse outcomes compared to aHVC and pHVC. These findings support selective referral strategies and regionalization of care.