Survival Comparison of the Ross Procedure and Mechanical Valve Replacement With Optimal Self-Management Anticoagulation Therapy: Propensity-Matched Cohort Study

Study Questions:

Is there a survival difference among young patients after a Ross procedure (auto-graft aortic valve replacement [AVR]) compared to mechanical AVR with optimal self-management of anticoagulation therapy?

Methods:

A total of 1,324 patients (918 patients after Ross AVR and 406 patients after mechanical valve) 18-60 years of age without dissection, aneurysm, or mitral valve replacement who survived an elective procedure between 1994 and 2008 were analyzed for late survival. Using propensity score matching, 253 patients with a mechanical valve (mean follow-up 6.3 years) could be matched to a Ross patient (mean follow-up 5.1 years).

Results:

The mean age of the matched cohort was 47.3 years in the Ross procedure group and 48.0 years in the mechanical valve group (p = 0.17); the ratio of male to female patients was 3.2 in the Ross procedure group and 2.7 in the mechanical valve group (p = 0.46). Linearized all-cause mortality rate was 0.53% per patient-year in the Ross procedure group compared with 0.30% per patient-year in the mechanical valve group (matched hazard ratio, 1.86; 95% confidence interval, 0.58-5.91; p = 0.32). Late survival was comparable to that of the general German population.

Conclusions:

In comparable patients, there is no late survival difference in the first postoperative decade between the Ross procedure and mechanical aortic valve implantation with optimal anticoagulation self-management. Survival in these selected young adult patients closely resembles that of the general population, possibly as a result of highly specialized anticoagulation self-management, better timing of surgery, and improved patient selection in recent years.

Perspective:

The Ross procedure––in which the patient’s native and normal pulmonic valve is substituted for the diseased aortic valve, and a homograft used to replace the pulmonic valve––has been largely abandoned in adult cardiac surgery, except in a few centers and for a few discrete indications. Initial hopes that the procedure would be more durable in young patients have not come to fruition. In addition, the added surgical expertise that is required, as well as the inherent risk involved of iatrogenic conversion of single-valve disease (the aortic valve) to double-valve disease (the aortic and pulmonic valves) have led most surgeons and adult patients to more reproducible procedures. This study appears to make two statements: first, 'long-term' mortality with the Ross procedure is no better than that after mechanical AVR; and second, self-control of anticoagulation is superior and could help yield superior outcomes after mechanical AVR. As to the first point, mean follow-up of 5-6 years in young patients cannot constitute 'long-term' outcomes; and outcomes that are long-term should assess more than all-cause mortality (including freedom from all valve-related morbidity, as well as assessment of quality of life). The use of self-monitored anticoagulation also must account for the population, and the control achieved in a German population might not readily extrapolate to the general population in the United States. Perhaps the best take-home message from this study is that, if a patient elects to undergo mechanical AVR, short-term outcomes in conjunction with tight control of anticoagulation appear to be no worse than short-term outcomes after a more esoteric procedure. Phrased this way, the findings of the study seem less noteworthy.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Heart Valve Prosthesis, Follow-Up Studies, Propensity Score, Hypoglycemic Agents, Pulmonary Valve, Cardiac Surgical Procedures, Mitral Valve, Thiazolidinediones, United States


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