Ross procedure provides survival benefit over mechanical valve in adults: a propensity-matched nationwide analysis

Abstract

OBJECTIVES The choice of optimal surgical treatment for young and middle-aged adults with aortic valve disease remains a challenge. Mechanical aortic valve replacement (mAVR) is generally preferred despite promising recent outcomes of the Ross procedure. Our goal was to compare the strategies at a nationwide level. METHODS This study was a retrospective analysis of prospectively recorded data from the National Registry of Cardiac Surgery of the Czech Republic. Using propensity score matching, we compared the outcomes of patients undergoing the Ross procedure in 2 dedicated centres with all mAVRs performed in country between 2009 and 2020. RESULTS Throughout the study period, 296 adults underwent the Ross procedure and 5120 had an mAVR. We found and compared 291 matched pairs. There were no in-hospital deaths, and the risk of perioperative complications was similar in both groups. Over the average follow-up period of 4.1 vs 6.1 years, the Ross group had a lower all-cause mortality (0.7 vs 6.5%; P = 0.015). This result remained significant even when accounting for cardiac- and valve-related deaths only (P = 0.048). Unlike the Ross group, the mAVR group had a significantly lower relative survival compared with the age- and sex-matched general population. There was no difference in the risk of reoperation (4.5 vs 5.5%; P = 0.66). CONCLUSIONS The Ross procedure offers a significant midterm survival benefit over mAVR. The procedures have a comparable risk of perioperative complications. Patients after mAVR have reduced survival. Thus, the Ross procedure should be the preferred treatment option for young and middle-aged adults with aortic valve disease in dedicated centres.

Ross Procedure Versus Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Network Meta‐Analysis

“…In addition, 21 articles were excluded with the following reasons: n=10: no comparison or control groups; n=4: neither randomized nor PSM; n=3: pediatric patients aged <16 years; n=2: review article; n=1: no outcomes of interest reported; and n=1: trial protocol. Ten articles met the inclusion criteria and were assessed for the systematic review and the meta‐analysis 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 29 (Figure S1 ). Of those, 2 were RCTs 10 , 29 and 8 were PSM studies, 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 which enrolled a total of 4812 patients who received the Ross procedure (n=1991), M‐AVR (n=2019), or B‐AVR (n=802).…”

“…Ten articles met the inclusion criteria and were assessed for the systematic review and the meta‐analysis 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 29 (Figure S1 ). Of those, 2 were RCTs 10 , 29 and 8 were PSM studies, 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 which enrolled a total of 4812 patients who received the Ross procedure (n=1991), M‐AVR (n=2019), or B‐AVR (n=802).…”

“…Several long‐term observational studies of the Ross procedure, some of which contain series of contemporary modifications of surgical techniques, have shown favorable results. 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 Despite the large body of cumulative evidence demonstrating restored survival after the Ross procedure, the recognition of the Ross procedure in our community remains sparse. In the 2020 American College of Cardiology/American Heart Association valve guidelines, there is a class IIb recommendation for use of the Ross procedure in patients aged <50 years, 19 whereas there is no description of the Ross procedure in the 2021 European guidelines.…”

Comparison of bicuspidization and Ross procedure in the treatment of unicuspid aortic valve disease in adults – Insight from the AVIATOR registry

“…The incidence of MACCE was extremely low and comparable in both cohorts. According to the latest evidence, the Ross procedure is the only valve substitute to offer the patients survival comparable with age- and sex-matched general population ( 23 – 25 ). Despite very favorable long-term outcomes in the first two decades, the most recent insight from the German Ross Registry indicates a trend toward impairment of autograft and homograft function in the third decade accompanied by a decline of survival of Ross patients ( 26 ).…”

Pulmonary conduit reoperation following the Ross procedure

“…There has been a resurgence of interest in the Ross procedure for this cohort with increasing evidence suggesting that Ross patients may confer superior long-term outcomes compared to conventional aortic valve replacement (AVR) [ 1 ]. In this issue of the Journal , Gofus et al [ 2 ] evaluated mid-term outcomes of the Ross procedure compared to a propensity-matched cohort of mechanical AVR. The authors reported a lower all-cause mortality in the Ross cohort even after adjusting for only cardiac and valve-related deaths with no difference in risk of aortic reoperation.…”