The Ross procedure—a complex cardiac surgical technique for aortic valve replacement—is associated with significant long-term durability and excellent outcomes in a wide population of adult patients with aortic valve disease, the findings of a study of more than 450 patients undergoing the procedure at a high-volume north American centre have demonstrated.
Writing in a special cardiovascular surgery focus edition of the Journal of the American College of Cardiology (JACC), Ismail El-Hamamsy (Icahn School of Medicine at Mount Sinai, New York, USA) and colleagues detail long-term clinical and echocardiographic outcomes of Ross patients treated at the Montreal Heart Institute (Montreal, Canada) from 2011 to 2019.
The Ross procedure is a complex operation where a surgeon replaces the diseased aortic valve with the patient’s own living pulmonary valve, which is a mirror image of a normal aortic valve.
In their JACC paper, El-Hamamsy and colleagues acknowledge that there has been a “significant increase in the number of Ross procedures performed worldwide”, in part due to an appreciation of the loss of life expectancy observed following prosthetic aortic valve replacement in non-elderly adults.
Unlike conventional aortic valve replacement using tissue or mechanical valves—which either carry the need for patients to receive lifelong anticoagulation or a risk of deterioration over time—the Ross procedure provides a living autologous valve in the aortic position. Through adaptation, the valve can replicate the biological and haemodynamic properties of the native aortic valve, the researchers say, and these unique characteristics contribute to improved long-term outcomes compared with biological or mechanical valves.
The study followed 455 adults who underwent the Ross procedure performed by El-Hamamsy and his team. Patients participated in a dedicated follow-up programme that included regular clinical evaluations and annual echocardiograms. The mean patient age was 48. Half the cohort were older than 50 and10% were older than 60, with the oldest patient being 67.
At 12 years after surgery, survival was equivalent to that of the general population. More than 96% of the patients did not require cardiac reintervention, and more than 98% had no significant aortic valve dysfunction. Fewer than 1% required permanent pacemaker implantation, substantially lower than rates reported following conventional aortic valve replacement.
No patients experienced patient-prosthesis mismatch, and there were no cases of aortic valve endocarditis. Among the 3.5% of patients who required additional intervention within 12 years, most were successfully treated using minimally invasive transcatheter techniques rather than repeat open surgery.
The investigators also compared outcomes between patients with aortic stenosis and those with aortic regurgitation. For the first time, no differences were observed in aortic valve function or need for reintervention at 12 years, opening the way for consideration of the Ross procedure in this patient population, according to the researchers.
“The Ross procedure is the only aortic valve replacement operation that has consistently been shown to restore life expectancy to that of the general population matched for age and sex,” comments El-Hamamsy. “This comprehensive longitudinal study highlights the unique advantages of the Ross procedure in adults, including outstanding valve durability and excellent long-term clinical outcomes. Importantly, our findings challenge longstanding assumptions by demonstrating excellent results in patient groups that have historically been overlooked.”
