Patients who received Ross procedure demonstrate excellent survival rates after 20 years, reports study
Young patients who have undergone the Ross procedure for aortic valve disease have shown excellent long-term survival, the majority without the need for additional surgery two decades later.
These findings, presented today at the 61st annual meeting of The Society of Thoracic Surgeons (STS), were the result of a 22-year study at the Narayana Institute of Cardiac Sciences in Bengaluru, India.
“The Ross operation can be performed safely with results comparable to mechanical valve replacement,” said the study’s lead author, cardiac surgeon Varun Shetty, MBBS, DNB (CVTS). “It has the added advantage of avoiding oral anticoagulation drugs and the risks associated with lifelong anticoagulation. In fact, most of our patients are not on any cardiac medications following one year after surgery.”
Dr. Shetty’s team followed 252 patients who underwent the Ross procedure, a heart valve replacement operation commonly used to treat younger patients with severe aortic valve disease. During the surgery, the malfunctioning aortic valve is replaced with the patient’s own healthy pulmonary valve-a technique called an autograft-and the pulmonary valve replaced with donor tissue.
“The main drawback of the Ross operation is failure of the autograft over time,” Dr. Shetty said. “We wanted to examine our outcomes, and we were pleasantly surprised to find that the freedom from re-intervention was 91% at 10 years and 87% at 20 years.”
Of the 252 patients in the study, 186 underwent a cylinder inclusion technique, or “mini root” replacement, while 25 received a Dacron-reinforced autograft. Three patients underwent the Ross-Konno procedure, in which the left-sided outflow root is enlarged to fit the pulmonary autograft. Twenty-five patients also received an ascending aorta replacement, two received hemiarch replacement, and four underwent septal myectomy-removal of abnormally thickened heart muscle.
At follow-up, Dr. Shetty’s team found that survival rates were 95.8% at 5 years, 94.3% at 10 years, 93.3% at 15 years, and 90.3% at 20 years. “Freedom from aortic regurgitation was 95.1%, 92.2%, 87.7%, and 84.5% at 5,10,15 and 20 years respectively,” the researchers reported.
Freedom from pulmonary regurgitation was lower—97% at 5 years, 83.6% at 10 years, 79.7% at 15 years, and 75.1% at 20 years.
“Individuals aged 18 years or younger exhibit notably higher rates of aortic regurgitation,” Dr. Shetty observed. “Risk factors for late autograft dysfunction include a dilated aortic annulus and ascending aorta.”
“Stabilization of the aortic annulus and pulmonary autograft will improve the re intervention rate in the future,” he added.
Because the Ross procedure uses living tissue, it not only can circumvent the need for anticoagulant medication, but also allows the valves to grow along with a growing child.
“The most important message from our study is that the Ross procedure offers excellent long-term survival rates with low risk of re-intervention even at 20 years,” Dr. Shetty said. “This makes the Ross operation an excellent substitute for mechanical valve replacement.”
Dr. Shetty’s team benchmarked their results with those recorded in the STS Congenital Heart Surgery Database (CHSD)-which contains more than 600,000 congenital heart surgery procedure records and currently has more than 1,000 participating physicians, including surgeons and anesthesiologists.
“Our study, performed at a single high-volume surgical center in India, demonstrates that the Ross operation can be performed with reproducible success across the globe,” Dr. Shetty said.
The CHSD is part of the STS National Database, one of the largest and most comprehensive clinical registries with nearly 10 million cardiothoracic procedures performed by 4,300+ surgeons. With over 95% of adult and congenital cardiac surgery procedures and a majority of lung cancer and esophageal cancer surgery in the U.S., the data and outcomes from the STS Database specialty registries provide true national benchmarks for clinical outcomes of cardiothoracic surgery.
