Survival After Ross Procedure Compared to Mechanical AVR

Study Questions:

What is the long-term survival difference between the Ross procedure and mechanical aortic valve replacement (AVR)?


The investigators compared 392 Ross procedures performed between 1992 and 2016 to 1,928 isolated mechanical AVRs performed during the same time period, as identified using the University of Melbourne and Australia and New Zealand Society of Cardiac and Thoracic Surgeons’ Cardiac Surgery Databases. They included only patients between 18 and 65 years of age. Propensity-score matching was performed for risk adjustment. The Kaplan-Meier method was used to analyze unadjusted survival, which was compared using the log-rank test.


Ross procedure patients were younger, and had less cardiovascular risk factors. The Ross procedure was associated with longer cardiopulmonary bypass and aortic cross-clamp times. Thirty-day mortality was similar (Ross: 0.3%, mechanical: 0.8%, p = 0.5). Ross procedure patients experienced superior unadjusted long-term survival at 20 years (Ross: 95% vs. mechanical: 68%, p < 0.001). Multivariable analysis showed the Ross procedure to be associated with a reduced risk of late mortality (hazard ratio, 0.34; 95% confidence interval, 0.17-0.67, p < 0.001). Amongst 275 propensity-score matched pairs, Ross procedure patients had superior survival at 20 years (Ross: 94% vs. mechanical: 84%, p = 0.018).


The authors concluded that in this propensity-score matched study, the Ross procedure was associated with better long-term survival compared with mechanical AVR.


This long-term, propensity-score matched study reports that the Ross procedure is associated with better long-term survival in suitable patients compared to mechanical AVR. The survival benefit may be partially explained by the lack of need for anticoagulation and its complications, and may also reflect the more favorable valve hemodynamics associated with a Ross procedure, whereby the effective orifice area is much greater than that which can be achieved with a prosthesis. It would seem reasonable to consider the Ross procedure in appropriately selected younger patients, with a long life expectancy in centers with sufficient expertise.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Aortic Valve, Cardiopulmonary Bypass, Cardiac Surgical Procedures, Heart Defects, Congenital, Heart Valve Diseases, Heart Valve Prosthesis, Hemodynamics, Risk Adjustment, Risk Factors, Survival, Transcatheter Aortic Valve Replacement

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