Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure

Abstract

IMPORTANCEThere is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed.OBJECTIVE To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure. DESIGN, SETTING, AND PARTICIPANTSA retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018.MAIN OUTCOMES AND MEASURES Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling.RESULTS During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13 015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year).CONCLUSIONS AND RELEVANCE Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.

Lifetime management of aortic valve disease: Aligning surgical and transcatheter armamentarium to set the tone for the present and the future

“…[53][54][55] In this scenario, the Ross procedure has triggered a new wave of enthusiasm over the last decades. [56][57][58][59] Starnes et al 56 studied outcomes of two cohorts of adults (aged ≥18 years) with bicuspid aortic valves undergoing the Ross procedure. Mortality rates at 1, 5, and 10 years, respectively, was 2.8%, 2.8%, and 4.4% in the first cohort and 0%, 0%, and 0% in the second cohort.…”

“…Romeo et al 58 conducted a multicentric cohort including 1431 patients with a median age of 48.5 years. The in‐hospital mortality rate was 0.7%.…”

“…This option is even more problematic in women of childbearing age who desire children 53–55 . In this scenario, the Ross procedure has triggered a new wave of enthusiasm over the last decades 56–59 …”

Application of Homograft Valved Conduit in Cardiac Surgery

“…Female sex was significantly associated with lower gradients of homografts, but also increased the likelihood of significant regurgitation. In contrast, the use of homografts rather than bioprosthesis and older donor age was associated with a lower likelihood of significant regurgitation ( 39 ). Another study showed that age and homograft diameter at the time of operation was also associated with valve function ( 40 ).…”

The Year in Review: Anesthesia for Congenital Heart Disease 2021

“…Freedom from autograft and homograft intervention was 92 and 97%, respectively, during that time. 26…”