The Ross procedure: time for a hard look at current practices and a reexamination of the guidelines

Abstract

The ideal aortic valve substitute for young adults requiring aortic valve replacement (AVR) remains elusive. Young and middle-aged patients have a longer anticipated life expectancy and a higher level of physical activity than their elderly counterparts. In recent years, there has been a growing focus on long-term outcomes following AVR in this specific patient population. These studies highlight the direct impact of the choice of prosthesis on long-term survival, quality of life and rates of valve-related complications in younger adults. Although conventional AVR using a biological or mechanical prosthesis significantly improve the natural history of the disease, there are many inherent limitations, which need to be addressed. Despite declining use of the Ross procedure in recent years, several long-term registry, cohort and comparative studies in the last decade, indicate a clear role for this operation in young and middle-aged adults requiring AVR. These advantages are manifest in terms of long-term survival, freedom from valve-related complications and quality of life. In this Perspective article, we discuss findings from a recently published propensity-matched analysis of long-term outcomes following mechanical AVR versus the Ross procedure, showing better cardiac- and valve-related survival in the Ross cohort, lower rates of stroke and major bleeding and equal rates of reoperation at 20 years. These data are placed in the broader context of currently available evidence regarding the Ross procedure and a broader discussion pertaining to its role in today's practice and the need to reexamine current valvular guidelines so they are more reflective of the actual evidence.

Valve performance classification in 630 subcoronary Ross patients over 22 years

“…There is now clinical evidence that the Ross procedure in the young and middle-aged patients is associated with excellent outcome. [4][5][6][7][8][9][10] Long-term results are growing for the freestanding or inclusion technique [11][12][13] but are scarce for the original subcoronary technique. Furthermore, there is a lack of a practical VPC for comparison between different techniques and substitutes.…”

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

“…These results come at a time when the Ross operation is under much scrutiny, with several new studies reporting excellent long-term outcomes with this technique, achieving survival comparable with that of the general population 6 7. Several authors have suggested that the current guidelines regarding AVR in the young should be reconsidered with these new data in mind 33 34…”

Progress in cardiovascular bioprinting

“…The estimated cost of heart valve disease in the United States is 23.4 billion USD per year 96 . Bioengineering can address these issues with the fabrication of biologically compatible and mechanically functional heart valves, at potentially much lower cost 98‐100 …”