Aortic Valve Replacement and Ross Operation in the Young
What are outcomes after the various types of aortic valve replacement (AVR) in children and young adults?
AVR procedures were compared after advanced matching, both in pairs and in a three-way manner, using a Bayesian dynamic survival model.
A total of 2,767 patients with congenital aortic disease underwent AVR in the United Kingdom between 2000 and 2012. Of these, 671 were excluded because they were >40 years old, 193 because of co-existing complex heart abnormalities, 15 because of rheumatic fever, 313 because the type of AVR was not classified, and 74 because of unknown age at the time of the index procedure. Of the remaining 1,501 patients, 47.8% had a Ross procedure, 37.8% a mechanical AVR, 10.9% a bioprosthetic AVR, and 3.5% a homograft AVR. The Ross patients were significantly younger than the other groups. Overall survival at 12 years was 94.6%. In children, the Ross procedure had a 12.7% higher event-free probability (death or any reintervention) at 10 years when compared to mechanical AVR. In young adults, bioprosthetic valves had the lowest event-free probability of 78.8%, followed by comparable results with mechanical AVR and the Ross procedure (86.3% and 89.6%, respectively.) Younger age was associated with mortality and pulmonary reintervention in the Ross group and with aortic reintervention in the mechanical AVR group. Of the three options, only patients undergoing the Ross procedure approached the survival of the general population.
The authors concluded that AVR in the young achieves good results, with the Ross procedure overall better suited for this age group, especially in children.
Selection of the optimal mode of AVR remains a challenge. Limitations of the Ross procedure include potential need for reintervention on the pulmonary valve as well as aortic dilatation. Bioprosthetic valves may have issues with durability. Mechanical valves are associated with the inherent risks of anticoagulation. This nationwide study from the United Kingdom shows excellent results for the Ross procedure, both for operative mortality and the need for reintervention. It is possible that with longer-term follow-up, issues with aortic dilatation may become more apparent, though modifications in the technique aimed at reducing aortic dilatation have shown promise in multiple single-center studies. This study demonstrates that the Ross procedure is a good option, particularly in young patients.
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