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In experienced hands, the Ross procedure was associated with favorable short- and long-term outcomes in young patients requiring aortic valve replacement (AVR), according to a retrospective cohort study.

Survival was 95.1% at 10 years -- 88.5% at 15 years -- among more than 1,400 adults undergoing the double-valve procedure at highly specialized centers, Mostafa Mokhles, MD, PhD, of Utrecht University Medical Center in The Netherlands, and colleagues reported.

"The Ross procedure continues to be the only living-valve alternative in young and middle-aged patients with a reported survival that compares with the general population well into the second postoperative decade," the group wrote in .

Freedom from either autograft- or homograft-related reintervention was a respectable 90.8% at 15 years, broken down into 92.0% freedom from autograft-related reintervention and 97.2% freedom from homograft-related reintervention.

Both the autograft and homograft showed stable and predictable changes in transvalvular gradient during the first 20 years postoperatively, Mokhles' group noted.

Furthermore, late events were infrequent following the Ross procedure:

• Autograft endocarditis in 14 patients (0.11% per patient-year)
• Homograft endocarditis in 11 patients (0.08% per patient-year)
• Stroke in 37 patients (0.3% per patient-year)

Given these short- and long-term results, the Ross procedure should be considered in young and middle-aged adults requiring AVR, especially when performed at an experienced center with a program dedicated to the procedure, the investigators said.

"Despite excellent results, the Ross procedure remains an underused treatment, limited to experienced centers and surgeons. Its limited use is often attributed to the complexity of the procedure and concerns about increased risks of early mortality and late reintervention," they noted.

"The net effect has been that very few surgical centers in the U.S. have maintained expertise in the Ross procedure and it is not discussed as a treatment option for many young patients who are potential candidates," according to from Robert Bonow, MD, MS, of Northwestern University Feinberg School of Medicine in Chicago, and Patrick O'Gara, MD, of Brigham and Women's Hospital in Boston.

Mokhles and colleagues reported that 0.7% of patients died before discharge, well within the 0.4-2.3% range expected of experienced centers and comparable with many routine surgical procedures.

"Technical complexities can thus be overcome without increased early mortality given sufficient operative volumes," they argued, urging "more proctoring, specialized training and education, and better access to the small number of specialized centers."

The only alternative to mechanical and bioprosthetic valves for AVR, the Ross is a surgical procedure where the aortic valve is replaced with the patient's own pulmonary valve, followed by reconstruction of the continuity of the right ventricular outflow tract (RVOT) and pulmonary artery with a pulmonary homograft.

"One of the major advantages of the Ross procedure is the avoidance of permanent anticoagulation. No other durable AVR substitute that does not require anticoagulation is available," according to the study authors.

"The excellent autograft hemodynamics without need for long-term anticoagulation have translated into improved long-term outcomes with the Ross procedure compared with AVR with mechanical prostheses or aortic homografts," Bonow and O'Gara noted.

Guidelines are lukewarm on the Ross procedure, with the latest American College of Cardiology/American Heart Association guidelines giving it only a class IIb recommendation for patients younger than 50 years old even when performed at a comprehensive valve center by experienced surgeons.

The current study included 1,431 consecutive adults (74.3% men, median age 48.5 years) who were selected for the Ross procedure at one of five high-volume centers in Australia, Belgium, Brazil, Canada, and Germany. Median follow-up was 9.2 years.

Surgical implantation techniques included root inclusion (24.9%), root replacement (34.0%), and subcoronary implantation (41.1%). RVOT reconstruction was performed with homografts in 98.6% of cases and bioprostheses in the remainder.

Mokhles and colleagues acknowledged that the results achieved in this study may be hard to replicate among less experienced surgeons.

"It is unlikely that these results currently could be replicated more broadly in other academic institutions and community hospitals," agreed Bonow and O'Gara.

The duo called for randomized trials testing the Ross procedure in young patients.

"Future studies should include even longer follow-up, ideally into the third decade, including matched comparisons with patients undergoing mechanical AVR and the general population. Furthermore, new studies addressing the quality of life given permanent oral anticoagulation are needed to more closely determine its effect on long-term quality of life," according to the investigators.

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