Ross procedure significantly improves postoperative survival among patients of aortic valve disease: JAMA

In the post hoc analysis of a randomized clinical trial of 108 adults who underwent the Ross procedure, the researchers reported that survival into the third postoperative decade was 83%, similar to that in the matched general population.

Heart valve disease is a prevalent condition that affects about 74 million patients globally. The absolute number of deaths due to aortic valve disease tripled between 1979 and 2009 making it responsible for the highest proportion of deaths within the spectrum of valvular heart disorders. For several years, the standard of care for the surgical treatment of AVD patients has been prosthetic aortic valve replacement (AVR).

In previous studies, survival after prosthetic AVR in adults younger than 65 years is shown to be significantly lower than in the general population. Interest in valve repair has grown, but most AVD patients require replacement of their valves. Recently, a renewed interest has gathered around the Ross procedure (pulmonary autograft) for AVD treatment in adults.

Maximiliaan L. Notenboom, Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues aimed to evaluate the long-term echocardiographic and clinical outcomes following the Ross procedure for the treatment of adults with AVD.

For this purpose, the researchers conducted a post hoc analysis of an RCT that included adult patients (age <69 years) who underwent a Ross procedure for AVD treatment, including those with rheumatic AVD, active endocarditis, previous cardiac surgery, and decreased ejection fraction.

The trial which was conducted from 1994 to 2001 compared homograft root replacement with the Ross procedure at a single center.

The primary endpoint of the study was determined as long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin– and sex-matched general population. Secondary endpoints were freedom from any reintervention, homograft intervention, or autograft intervention, and time-related valve function, functional status, and autograft diameter.

The study led to the following findings:

• The study included 108 adults with a median age of 38 years. The median duration of clinical follow-up was 24.1 years, with 98% follow-up completeness. Of these patients, 8% had active endocarditis and 42% underwent reoperations.
• The main hemodynamic lesion was stenosis in 28% and regurgitation in 45%.
• There was 1 perioperative death. Twenty-five-year survival was 83.0%, representing a relative survival of 99.1% compared with the general population (83.7%).
• At 25 years, freedom from any reintervention was 71.1%; from autograft reintervention, 80.3%; and homograft reintervention, 86.3%.
• Thirty-day mortality after the first Ross-related reintervention was 0%, and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2%.

The study found that in adults with AVD, the Ross procedure led to excellent survival into the third decade after surgery which was equivalent to that in the general population. Additionally, long-term freedom from intervention shows that autograft is a durable aortic valve substitute into late adulthood, showing a delayed but progressive functional decline.

"These data further support the unique benefits of a living valve substitute in adults and suggest that this effect sustains into the third postoperative decade," the researchers concluded.

Reference:

Notenboom ML, Melina G, Veen KM, et al. Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Cardiol. Published online November 08, 2023. doi:10.1001/jamacardio.2023.4090