Outcomes in Young and Middle-Aged Adults Undergoing the Ross Procedure
Quick Takes
- At five experienced international centers, the Ross procedure was associated with excellent long-term survival and low re-intervention rates.
- Patients should be referred to an experienced center with a program dedicated to the Ross procedure.
Study Questions:
What are the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure?
Methods:
A retrospective multicenter international cohort study was performed at five experienced centers. Consecutive patients aged 18-65 years were included by each center between 1991 and 2018. Outcome measures included survival, autograft-related intervention, and echocardiographic measures of valve function.
Results:
The median follow-up period was 9.2 years. A total of 1,431 patients had surgeries at a median age of 48.5 years (mean [standard deviation], 47.7 [9.5]; range 18.1-65; interquartile range, 42.7-54 years). Implantation techniques included root inclusion in 355 (24.9%), root replacement in 485 (34%), and subcoronary implantation in 587 (41.1%). Homografts were used in the right ventricular outflow tract in 98.6% of patients, while bioprosthetic valves were used in the remainder. Ten patients (0.7%) died before discharge. Survival was 95.1% at 10 years and 88.5% at 15 years. Freedom from autograft intervention was 92% at 15 years, while freedom from homograft re-intervention was 97.2%.
Conclusions:
The authors concluded that, based on excellent short- and long-term outcomes, the Ross procedure should be considered in young and middle-aged adults requiring aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.
Perspective:
The Ross procedure had fallen in and out of favor over the last several decades. Multiple studies over the last several years have shown excellent long-term survival, restoring life-expectancy to that of an age- and sex-matched general population for at least 15 years post-procedure. The current study shows excellent mid- and long-term survival after the Ross procedure, with extremely low re-intervention rates. Historical concerns for the Ross have included taking a patient with ‘one-valve disease’ and giving them ‘two-valve disease’ as well as the need for re-intervention for autograft dysfunction or aortic dilatation. This study is reassuring on both accounts. An important component of the Ross procedure is the technique of supporting the autograft to prevent dilatation, which is an area requiring further study. The Ross procedure should be included in the discussion of options for aortic valve replacement in young and middle-aged patients and should be performed at experienced centers.
Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Quality Improvement, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Aortic Valve, Autografts, Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Dilatation, Echocardiography, Heart Defects, Congenital, Heart Valve Diseases, Heart Valve Prosthesis, Middle Aged, Outcome Assessment, Health Care, Transplantation, Autologous, Young Adult
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