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Long-Term Outcomes Following the Ross Procedure
Quick Takes
- In adults with aortic valve disease (AVD), the Ross procedure provided excellent survival into the third decade after surgery, which was equivalent to that in the general population.
- These data further support the unique benefits of a living valve substitute in adults that preserves mobility of the neo-aortic root and suggest that this effect sustains into the third postoperative decade.
- The Ross procedure may be the best valve replacement option for young, healthy AVD patients with long life expectancy.
Study Questions:
What are the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with aortic valve disease (AVD)?
Methods:
The investigators conducted a post hoc analysis of a randomized clinical trial and included adult patients (ages <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. The primary endpoint was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin–, and sex-matched general population. Secondary endpoints were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. Univariable Cox proportional hazards regression models were used to investigate factors associated with mortality and reintervention.
Results:
This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (interquartile range, 22.6-26.1 years; 2,488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was one perioperative death (0.9%). Survival at 25 years was 83.0% (95% confidence interval [CI], 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%).
Conclusions:
The authors report that the Ross procedure provided excellent survival into the third decade postoperatively, which was comparable to that in the general population.
Perspective:
This study reports that in adults with AVD, the Ross procedure provided excellent survival into the third decade after surgery, which was equivalent to that in the general population. Additionally, long-term freedom from reintervention demonstrates that the autograft is a durable aortic valve substitute into late adulthood, showing a delayed but progressive decline in function. These data further support the unique benefits of a living valve substitute in adults that preserves mobility of the neo-aortic root and suggest that this effect sustains into the third postoperative decade. The additional insight into the very long-term outcomes of the Ross procedure from this study suggests that this may be the best valve replacement option for young, healthy AVD patients with long life expectancy.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Cardiac Surgery and CHD and Pediatrics
Keywords: Aortic Valve Disease, Cardiac Surgical Procedures, Echocardiography
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