Ross Procedure vs Prosthetic Aortic Valve Replacement and Long-Term Outcomes

aortic valve replacement
A study was conducted to compare long-term outcomes following Ross procedure vs biological and mechanical avr in adults.

A retrospective review of health records found that the Ross procedure was associated with improved long-term survival and freedom from valve-related complications compared with prosthetic aortic valve replacement (AVR). These findings were published in the Journal of the American College of Cardiology.

Investigators at the Icahn School of Medicine at Mount Sinai sourced data from the California and New York mandatory reporting databases. To adjust for baseline differences, using a propensity score matching approach, all patients who received primary AVR using the Ross procedure (pulmonary autograft; n=434) or received a prosthetic AVR (biological: n=434; mechanical: n=434) between 1997 and 2014 were assessed for long-term outcomes.

The Ross, biological, and mechanical cohorts were aged mean 35.9±9.2, 36.2±9.4, and 36.7±8.8 years; 75%, 73%, and 78% were men; 74%, 71%, and 71% were White; 18%, 18%, and 19% had hypertension; and 15%, 15%, and 14% had congestive heart failure, respectively.

At 30 days, the mortality rate was 0.23% for Ross, 0.69% for biological AVR, and 0.69% for mechanical AVR (P =.71). At year 15, the survival rates were 93.2%, 87.9%, and 88.4% (P =.005), respectively. Mortality risk was lower for the Ross procedure compared with biological (hazard ratio [HR], 0.42; 95% CI, 0.23-0.75; P =.003) or mechanical (HR, 0.45; 95% CI, 0.26-0.79; P =.006) AVR.

At 15 years, the cumulative stroke incidence was 2.1% for the Ross procedure compared with 3.3% (HR, 0.61; 95% CI, 0.24-1.57; P =.30) for the biological AVR and 4.8% (HR, 0.37; 95% CI, 0.16-0.89; P =.03) for the mechanical AVR.

Major bleeding occurred at a rate of 1.9% for the Ross procedure compared with 3.3% (HR, 0.50; 95% CI, 0.19-1.32; P =.16) and 5.2% (HR, 0.32; 95% CI, 0.13-0.81; P=.016) for the biological and mechanical AVR, respectively.

Cumulative aortic and pulmonary valve reintervention occurred among 17.2% of Ross, 29.8% (HR, 0.63; 95% CI, 0.45-0.88; P =.008) of biological AVR, and 7.4% (HR, 2.4; 95% CI, 1.5-3.8; P =.0002) of mechanical AVR recipients.

For endocarditis, at 15 years, the rate was 2.3% among Ross procedure recipients compared with 8.5% (HR, 0.37; 95% CI, 0.17-0.80; P =.012) for biological AVR and 3.7% (HR, 0.61; 95% CI, 0.25-1.50; P =.61) for mechanical AVR.

These findings may not be generalizable, as patients who were aged 50 years or older or who had important comorbid conditions were excluded from this analysis.

“This study further confirms the notion that a living valve substitute in the aortic position translates into improvements in clinically relevant outcomes in young adults,” the study authors noted. “The Ross procedure should be considered the option of choice for young adults requiring isolated replacement of the aortic valve, provided it is performed in centers with Ross procedure expertise to ensure safety and durability.”


El-Hamamsy I, Toyoda N, Itagaki S, et al. Propensity-matched comparison of the Ross procedure and prosthetic aortic valve replacement in adultsJ Am Coll Cardiol. Published online March 1, 2022. doi:10.1016/j.jacc.2021.11.057