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Ross Procedure vs. Prosthetic Aortic Valve Replacement in Adults
Quick Takes
- A retrospective, propensity-matched analysis of young adults compared the Ross procedure to prosthetic (biological and mechanical) AVR.
- The Ross procedure was associated with better 15-year survival than biological or mechanical AVR.
- The Ross procedure had a significantly lower risk of endocarditis and reoperation compared to bioprosthetic valves and lower risk of bleeding and stroke compared to mechanical valves.
Study Questions:
In young adults (aged 18–50 years) undergoing elective primary aortic valve surgery, what are the long-term outcomes following the Ross procedure versus biological and mechanical aortic valve replacement (AVR)?
Methods:
This was a retrospective analysis of databases in New York State and California between 1997–2014 of young adults (aged 18–50 years) who underwent elective isolated AVR using either a pulmonary autograft (Ross procedure) or prosthetic (biological or mechanical) AVR.
To adjust for selection bias and possible patient- or institution-related confounders, a 1:1:1 (Ross: Biological; Mechanical) propensity-matched analysis was applied with strict exclusion criteria (≥1 concomitant procedure, reoperations, infective endocarditis, intravenous drug use, hemodialysis, history of cancer, connective tissue disorders, and out-of-state residency). The primary endpoint was all-cause mortality, and secondary endpoints included stroke, major bleeding (requiring inpatient admission), reoperation (including any reoperation on the pulmonary valve for the Ross procedure group), and acute endocarditis.
Results:
A total of 16,402 patients underwent primary AVR in California and New York State between 1997–2014. After applying exclusion criteria, 8,813 patients remained, of whom 446 underwent a Ross procedure, 2,795 a biological AVR, and 5,582 a mechanical AVR. Three-way 1:1:1 propensity score matching created 434 patients for each cohort, with no significant differences in demographic characteristics or comorbidities. Median follow-up was 12.5 years (interquartile range, 9.3-25.7 years).
Actuarial survival at 15 years following the Ross procedure was 93.1% (95% confidence interval [CI], 89.1-95.7%), which was similar to that of an age-, sex-, and race-matched US general population. Survival was significantly lower after biological AVR (87.9%; 95% CI, 83.2-90.6%) and mechanical AVR (88.4%; 95% CI, 84.4-91.5%). Furthermore, the Ross procedure was associated with a lower cumulative risk of endocarditis (HR, 0.37; 95% CI, 0.17-0.80; p = 0.012) and reoperation (HR, 0.63; 95% CI, 0.45-0.88, p = 0.008) than biological AVR. In contrast, the Ross procedure was associated with a higher risk of reoperation than mechanical AVR (HR, 2.4; 95% CI, 1.5-3.8; p < 0.001), but a lower risk of stroke (p = 0.03) and major bleeding (p = 0.016). The 30-day mortality after valve-related complications was highest for endocarditis (13.5%) and stroke (5.6%) and lowest for reoperation (1.1%).
Conclusions:
In a propensity-matched comparison of young adults undergoing isolated AVR, the Ross procedure was associated with better long-term survival than prosthetic AVRs. The Ross procedure had a significantly lower risk of endocarditis and reoperation compared to bioprosthetic valves. While the rate of reoperation was lowest with mechanical AVR, it was also associated with a significantly higher risk of major bleeding and stroke.
Perspective:
Historically, one of the largest issues with the Ross procedure in adults has been the need for possible reoperation on either the pulmonary or aortic valves. In more recent years, it has emerged as an alternative to prosthetic AVR, but most studies looking at survival after Ross have been small and from single centers. Considering that this larger state-wide study dates back to 1997, it is impressive that it already shows more favorable outcomes for the Ross procedure. With recent technical and technological modifications (such as decellularized pulmonary homografts), one would expect that contemporary outcomes have even further improved. That said, while propensity matching is able to account for patient demographics and comorbidities, as well as institutional experience, it is unlikely to account for the difference in individual surgeons. This may represent a significant confounder. Due to the complexity of the Ross procedure, further work is needed to standardize the procedure and identify objective measures to identify centers of 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, CHD and Pediatrics and Interventions, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease
Keywords: Aortic Valve Insufficiency, Allografts, Autografts, Cardiac Surgical Procedures, Endocarditis, Heart Valve Diseases, Heart Valve Prosthesis, Hemorrhage, Inpatients, Pulmonary Valve, Risk, Stroke, Transcatheter Aortic Valve Replacement, Transplantation, Autologous, Young Adult
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