The Ross procedure: Time to reevaluate the guidelines

Misfeld, Martín; Borger, Michael A.

doi:10.1016/j.jtcvs.2018.07.014

Cited by 13 publications

(8 citation statements)

References 8 publications

(8 reference statements)

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“…The Ross autograft operation is considered the gold-standard for AVR in young patients [ 6 ]. However, despite the excellent long-term results reported for the procedure, it has not been adapted by the vast majority of cardiac surgeons due to its technical complexity and a reluctance to create a potential 2-valve problem for the patient in the future.…”

Section: Introductionmentioning

confidence: 99%

Early results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement: the ARISE study and ARISE Registry data

Horke

Tudorache

Laufer

et al. 2020

European Journal of Cardio-Thoracic Surgery

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OBJECTIVES Decellularized aortic homografts (DAH) may provide an additional aortic valve replacement option for young patients due to their potential to overcome the high early failure rate of conventional allogenic and xenogenic aortic valve prostheses. METHODS A prospective, European Union-funded, single-arm, multicentre, safety study was conducted in 8 centres evaluating non-cryopreserved DAH for aortic valve replacement. RESULTS One hundred and forty-four patients (99 male) were prospectively enrolled between October 2015 and October 2018, mean age 33.6 ± 20.8 years; 45% had undergone previous cardiac operations. Mean implanted DAH diameter 22.6 ± 2.4 mm and mean durations for the operation, cardiopulmonary bypass and cross-clamp were 341 ± 140, 174 ± 80 and 126 ± 43 min, respectively. There were 2 early deaths (1 LCA thrombus on day 3 and 1 ventricular arrhythmia 5 h postop) and 1 late death due to endocarditis 4 months postoperatively, resulting in a total mortality of 2.08%. One pacemaker implantation was necessary and 1 DAH was successfully repaired after 6 weeks for early regurgitation following subcoronary implantation. All other DAH were implanted as a free-standing root. After a mean follow-up of 1.54 ± 0.81 years, the primary efficacy end points peak gradient (mean 11.8 ± 7.5 mmHg) and regurgitation (mean 0.42 ± 0.49, grade 0–3) were excellent. At 2.5 years, freedom from explantation/endocarditis/bleeding/stroke was 98.4 ± 1.1%/99.4 ± 0.6%/99.1 ± 0.9%/99.2 ± 0.8%, respectively, with results almost identical to those in an age-matched Ross operation cohort of 212 patients (mean age 34 years) despite DAH patients having undergone >2× more previous procedures. CONCLUSIONS The initial results of the prospective multicentre ARISE trial show DAH to be safe for aortic valve replacement with excellent haemodynamics in the short follow-up period.

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Section: Introductionmentioning

confidence: 99%

Early results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement: the ARISE study and ARISE Registry data

Horke

Tudorache

Laufer

et al. 2020

European Journal of Cardio-Thoracic Surgery

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show abstract

“…Current guidelines recommend that young adults requiring AVR should undergo mechanical AVR, despite the data supporting the Ross procedure for this patient population. The Ross procedure is the only valve replacement option that confers similar life expectancy as healthy individuals in the general population (26,58,59). It is associated with very low valve-related complications, and reoperations only increase after the second decade; however, these are generally done with excellent outcomes and are preferred over earlier mortality.…”

Section: Considering the Alternativementioning

confidence: 99%

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

Vervoort¹,

El-Hamamsy²,

Chu³

et al. 2021

Ann Cardiothorac Surg

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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.

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“…It is difficult to reconcile these guideline recommendations in the face of the published cohort, meta-analyses and randomized evidence supporting the advantages of the Ross procedure over conventional AVR options, particularly when performed in centers of expertise. Skeptics of the Ross procedure have argued that most published studies on its outcomes originate from specialized high-volume centers, which limits the external validity of this body of data (7)(8)(9)(10)(11)(12)17,18,(20)(21)(22)(23)(24)(25)(26)(27)80). However, this argument also applies to other highly specialized procedures such as complex valve repair, aortic arch or thoracoabdominal aortic repair and transcatheter valve interventions, which appear to have gained much broader appeal and guideline support than the Ross procedure.…”

mentioning

confidence: 99%

The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease

Hage¹,

Hage²,

Valdis³

et al. 2021

Ann Cardiothorac Surg

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While aortic valve repair remains the ideal intervention to restore normal valvular function, the optimal aortic valve substitute for patients with a non-repairable aortic valve remains an ongoing subject for debate. In particular, younger patients with a non-repairable valve represent a unique challenge because of their active lifestyle and long life expectancy, which carries a higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike prosthetic or homograft aortic valve replacement (AVR), provides an expected survival equivalent to that of the age and gender-matched general population. Contemporary data has shown that the Ross procedure can be performed safely in centers with expertise, and is associated with improved valvular durability, hemodynamics and quality of life.

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The Ross procedure: Time to reevaluate the guidelines

Abstract: Central Message The Ross procedure is associated with excellent long-term results in centers of expertise. Future versions of valve guidelines should more strongly recommend this option.

Cited by 13 publications

References 8 publications

Early results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement: the ARISE study and ARISE Registry data

Early results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement: the ARISE study and ARISE Registry data

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

The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease

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