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

Abstract

Prosthetic aortic valve replacements have long been the mainstay of valvular surgery due to their favorable outcomes and low operative complexity. Yet, mechanical valves require lifelong anticoagulation, whereas bioprosthetic valves increase the risk for earlier and more frequent reoperation. Alternative reconstructive techniques have been proposed to address these challenges. These include valve-sparing root replacement procedures if the native aortic valve can be salvaged, and the Ross procedure, which nearly eliminates prosthetic valve-related thromboembolism, anticoagulation-related hemorrhage and endocarditis. Both procedures are technically more complex and thus subject to surgeons' volume and expertise compared to conventional aortic valve replacements. However, they are associated with more favorable outcomes compared to aortic valve replacements if performed by experienced surgeons, especially in younger patients.Nevertheless, despite the growing high-quality literature supporting both procedures, existing multisociety guidelines fail to acknowledge the strength of evidence in support of valve-sparing root replacement procedures and the Ross procedure. In this review, we summarize the existing long-term evidence for the use of each procedure, describe the current guidelines for the treatment of aortic valve pathology, and propose the reevaluation of guidelines based on the available clinical evidence.

Aortic valve replacement in non-elderly: the gap between reality, guidelines and evidence

“…The median number of cardiac surgeons per centre is 6.0 . In Belgium this is 3.0 [2][3][4][5][6][7][8][9][10], in the USA 5.5 [1][2][3][4][5][6][7][8][9][10][11][12][13][14], in Canada 6.0 [4][5][6][7][8][9][10][11][12], in the UK this is 7.0 [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17], and in Germany 12.0 .…”

“…In the Ross performing centres, the median annual Ross number is 10.0 [1-100] with 69% of these centres performing less than or equal to ten cases per year. The median number of Ross performing surgeons in these specialised centres is 2.0 [1][2][3][4][5][6]. A mean of 7.3 Ross procedures are performed each year per cardiac surgeon in these centres.…”

“…The ACC/AHA (COR 2b LOE B) and ESC/EACTS guidelines (no specific recommendations), respectively, state that a Ross procedure may be considered 'in patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy at a Comprehensive Valve Centre' or 'in appropriately selected patients but high expertise in aortic surgery is required'. They both cite observational studies but consider the evidence insufficient, which can be questioned [ 6 ].…”