Repair of Unicuspid Aortic Valve Effective in Younger Patients

Before eventual pulmonary autograft replacement, younger patients in need of an aortic valve operation may benefit from valve repair.

Repair of a unicuspid aortic valve may be used as a bridge to eventual pulmonary autograft replacement, at least among younger patients, according to a study in the European Journal of Cardio-Thoracic Surgery.

Investigators assessed rates of reoperation and survival following valve repair compared with the Ross procedure for the unicuspid aortic valve in adults.

The retrospective analysis included patients who received treatment of a unicuspid aortic valve at a university medical center in Germany between December 1998 and April 2022. Overall, 345 patients (mean age, 33.5 [SD, 9.7] years; 74% men) received treatment. Individuals were excluded if they were aged younger than 18 years or older than 54 years at the time of the operation. A total of 258 patients were then categorized into 2 groups: 64% patients received valve repair and 91 (36%) patients had the Ross procedure (pulmonary autograft replacement).

The participants were followed prospectively, clinically and echocardiographically, at discharge, 3 months, 1 year, and yearly afterward. The main indications at the time of operation were isolated aortic stenosis (AS) in 45 patients (repair, 15%; Ross, 22%; P =.114), isolated aortic regurgitation (AR) in 104 patients (repair, 51%; Ross, 21%; P =.001, and combined disease in 103 patients (repair, 34%; Ross, 52%; P =.02). The patients who had valve repair were younger (mean age, 32 years) vs those who had a Ross procedure (mean age, 38 years; P =.061).

The median and mean follow-up were 5.1 years and 5.9 years, respectively. The follow-up was 95% complete, with 1512 patient-years.

The incidence of reoperation after the Ross procedure is low but remains poorly defined for UAVs [unicuspid aortic valves].

Early death after valve repair occurred in 1 patient, and 2 early reoperations also were performed in the repair group. In addition, 3 patients died at 3 months to 4.1 years postoperatively (repair, n=2; Ross, n=1). At 10 years, the overall survival was 98%. The 10-year survival was the same after valve repair (97%) and pulmonary autograft replacement (95%; P =.769).

For the repair group, reoperation-free survival was 77% at 10 years. The cumulative incidence of reoperation was 21% at 10 years and the cumulative mortality incidence was 2%. For the Ross group, reoperation-free survival was 94% at 10 years, with a cumulative incidence of reoperation of 2% and cumulative mortality incidence of 4%.

In analysis of patient age at the time of operation, among participants in the repair group, those aged 18 to 25 years had improved freedom from reoperation of 84% at 10 years vs older patients (ages 26-30 years, 54%; ages 31-40 years, 75%; ages 41-54 years, 66%; P =.347). Freedom from reoperation in the Ross group at 10 years was similar (94-96%) among all age groups (P =.934). Receiver operating characteristic curve analysis indicated a trend toward the best durability occurring in patients aged younger than 26 years.

The main study limitation is the observational design, as the analysis was performed retrospectively and treatment allocation was not randomized. In addition, the reproducibility of the findings may be limited owing to a highly experienced surgeon in a high-volume center performing the procedures.

“The incidence of reoperation after the Ross procedure is low but remains poorly defined for UAVs [unicuspid aortic valves],” wrote the study authors. “Thus, for patients younger than 25, repair may be used as a bridge to pulmonary autograft replacement, reserving Ross for repair failures.”


Abeln KB, Matsushima S, Ehrlich T, Giebels C, Schäfers H-J. Ross versus repair for treatment of the unicuspid aortic valve in adults. Eur J Cardiothorac Surg. Published online March 24, 2023. doi: 10.1093/ejcts/ezad118