Clinical and cost-effectiveness of the Ross procedure versus conventional aortic valve replacement in young adults

Abstract

ObjectivesIn young and middle-aged adults, there are three current options for aortic valve replacement (AVR), namely mechanical AVR (mechAVR), tissue AVR (biological AVR) and the Ross operation, with no clear guidance on the best option. We aim to compare the clinical effectiveness and cost-effectiveness of the Ross procedure with conventional AVR in young and middle-aged adults.MethodsThis is a systematic literature review and meta-analysis of AVR options. Markov multistate model was adopted to compare cost-effectiveness. Lifetime costs, quality-adjusted life years (QALYs), net monetary benefit (NMB), population expected value of perfect information (EVPI) and expected value of partial perfect information were estimated.ResultsWe identified 48 cohorts with a total number of 12 975 patients (mean age 44.5 years, mean follow-up 7.1 years). Mortality, bleeding and thromboembolic events over the follow-up period were lowest after the Ross operation, compared with mechAVR and biological AVR (p<0.001). Aortic reoperation rates were lower after Ross compared with biological AVR, but slightly higher when compared with mechAVR (p<0.001). At a willingness-to-pay threshold of £20effective. At a willingness-to-pay threshold of £20, 000 per QALY000 per QALY, the Ross procedure is more cost-effective compared the Ross procedure is more cost-effective compared withwith conventional AVR, with a lifetime incremental NMB of £60 conventional AVR, with a lifetime incremental NMB of £60 952 (952 (££3030 236236 to to ££7979 464). Incremental costs were £12464). Incremental costs were £12 323 (323 (££61086108 to to ££1515 972) and incremental QALYs 3.66 (1.81972) and incremental QALYs 3.66 (1.81 to to 4.76). The population EVPI indicates that a trial costing up to £2.03 million could be cost 4.76). The population EVPI indicates that a trial costing up to £2.03 million could be cost--effective.At a willingness-to-pay threshold of £20 000 per QALY, the Ross procedure is more cost-effective compared with conventional AVR, with a lifetime incremental NMB of £60 952 (£30 236 to £79 464). Incremental costs were £12 323 (£6108 to £15 972) and incremental QALYs 3.66 (1.81 to 4.76). The population EVPI indicates that a trial costing up to £2.03 million could be cost-effective.ConclusionsIn young and middle-aged adults with aortic valve disease, the Ross procedure may confer greater quality of life and be more cost-effective than conventional AVR. A high-quality randomised trial could be warranted and cost-effective.

Next-generation tissue-engineered heart valves with repair, remodelling and regeneration capacity

“…In addition, recent reports have shown that the Ross procedure improves life expectancy 52 and freedom from cardiac-and valve-related mortality, as well as reduces the risk of stroke and bleeding when compared to mechanical valve replacement 51 . These results indicate that, when properly performed, the Ross procedure represents a valuable option to treat aortic valve disease in young patients and may even provide a more cost-effective approach compared to conventional aortic valve replacement using a mechanical valve 53 . However, the technical complexity still remains a major challenge of the Ross procedure and therefore limiting its broad clinical adoption 51 .…”

The Ross procedure and valve-sparing root replacement procedures in the adult patient: do guidelines follow the evidence?

“…Applying a decision analysis microsimulation model, Tam et al illustrated that the Ross procedure is expected to outperform mechanical AVR in terms of life expectancy when perioperative mortality for the Ross procedure is less than 2.5%, which is the case in expert hands (54). Moreover, when comparing Ross versus AVR in young adults, the Ross procedure has been found to result in greater quality of life and more favorable cost-effectiveness compared to AVR (55,56). Although large randomized clinical trials…”

Formal consensus study on surgery to replace the aortic valve in adults aged 18–60 years

“…Patients in this age group can have conventional aortic valve replacement (AVR) with a tissue or a mechanical valve (tAVR, mAVR), or the pulmonary autograft (Ross) or aortic valve neocuspidisation (Ozaki) procedures. [2][3][4][5][6][7][8][9][10] Transcatheter aortic valve implantation (TAVI) may also be an option for selected patients in this age group, including those with low-to-moderate surgical risk. 11 The choice of valve is influenced by cardiologists, surgeons and patients; it is value sensitive and influences both quantity and quality of life.…”

“…In this manuscript, we focus on valves that are not amenable to repair. Patients in this age group can have conventional aortic valve replacement (AVR) with a tissue or a mechanical valve (tAVR, mAVR), or the pulmonary autograft (Ross) or aortic valve neocuspidisation (Ozaki) procedures 2–10. Transcatheter aortic valve implantation (TAVI) may also be an option for selected patients in this age group, including those with low-to-moderate surgical risk 11.…”

“…A mechanical valve is potentially permanent but requires lifelong anticoagulation and its attending complications, while a tissue valve degenerates over time and needs replacement every 10–15 years or sooner in younger patients 3 4. The Ross operation is technically complex and has been criticised for creating ‘double valve disease’, although meta-analyses of observational studies have shown excellent outcomes 1 2 5 10 12 13. The Ozaki procedure, which involves creating three new leaflets with hand-sewn pericardial patches (animal or autologous), has generally shown good mid-term results in young patients,6 7 although there have been issues related to the behaviour of the biomaterial used to reconstruct the leaflets 8 9…”