Survival up to 10 years is similar in patients aged younger than 50 years and in patients aged 50 years or older who have the Ross procedure for aortic valve disease, and survival up to 15 years is improved in younger patients, according to a study in the European Journal of Cardio-Thoracic Surgery.
Researchers retrospectively reviewed all patients who received a Ross procedure from 1994 to 2019 at a single center. The participants were categorized into the younger group (aged <50 years) and older group (aged ≥50 years) based on the age when they had the Ross procedure.
The primary endpoint was differences in survival up to 10 and 15 years between the younger and older patients who had the procedure.
A total of 225 patients had the Ross procedure during the study period, with 156 patients aged younger than 50 years and 69 patients aged 50 years or older. The mean age of the younger group was 36±8.1 years vs 55±4.2 years for the older group. A majority of patients were men in both groups (younger, 58.5%; older, 69.6%).
The younger group had a significantly increased rate of aortic insufficiency (51% vs 26.1%; P <.01), and aortic stenosis was significantly more common in the older group (25.6% vs 58.0%; P <.01). Younger patients also had an increased rate of bicuspid aortic valve (81.4% vs 58.0%; P <.01).
The younger group had an operative mortality rate of 1.3% compared with 4.3% in the older group (P =.15).
The median follow-up was 16.2 (IQR, 9.1-20.4) years in the younger group and 16.1 (IQR, 8.9-19.3) years in the older group. For all-cause mortality, survival up to 10 years was not statistically different in the 2 groups, with a survival rate of 96.2% in the younger group and 91.3% in the older group (log-rank P =.16; hazard ratio [HR], 2.3; 95% CI, 0.7-7.0). In the younger group, 6 patients (3.8%) died within 10 years compared with 6 (8.7%) who died in the older cohort.
Survival up to 15 years was significantly increased among younger patients vs older patients (94.9% vs 85.5%; log-rank P =.04; HR, 2.89; 95% CI, 1.1-7.3). Within 15 years, 8 patients (5.1%) had died in the younger group compared with 10 patients (14.5%) who died in the older group.
For both groups, the survival of patients who had the Ross procedure was not statistically different from the age- and sex-matched US general population (younger log-rank P =.27; older log-rank P =.70).
A competing risk analysis with multivariable subdistribution hazard models showed that being aged 50 years or older was associated with an increased risk of cardiac death in the 15-year follow-up (HR, 8.99; 95% CI, 1.02-79.2; log-rank P =.05) but not in the 10-year follow-up (HR, 6.78; 95% CI, 0.72-64.1; log-rank P =.10).
Limitations of the study include the retrospective design with participants from a single center. Also, the case selection and operative technique of Ross procedures changed over time, and the sample size of patients in the younger group is larger than the older cohort, which increases the risk of type 2 error.
“Our findings suggest that at experienced centers, the Ross procedure can be performed in carefully selected patients who are over 50 years old,” wrote the study authors. “While we hope that this series spurs debate, larger and multicenter studies are needed to update and establish the age range at which Ross procedure is a viable consideration for aortic valve disease.”
Shih E, Ryan WH, Squiers JJ, et al. Outcomes of the Ross procedure in patients older versus younger than 50 years old. Eur J Cardiothorac Surg. Published online July 13, 2023. doi: 10.1093/ejcts/ezad260