Propensity-Matched Comparison of the Ross Procedure and Prosthetic Aortic Valve Replacement in Adults

J Am Coll Cardiol. 2022 Mar 1;79(8):805-815. doi: 10.1016/j.jacc.2021.11.057.


Background: There has recently been renewed interest in the Ross procedure in adults.

Objectives: The goal of this study was to compare long-term outcomes after the Ross procedure vs biological and mechanical aortic valve replacement (AVR) in adults (aged 18-50 years) undergoing aortic valve surgery.

Methods: Mandatory California and New York databases were queried between 1997 and 2014. Exclusion criteria included: ≥1 concomitant procedure, reoperations, infective endocarditis, intravenous drug use, hemodialysis, and out-of-state residency. Propensity matching (1:1:1) was used, resulting in 434 patients per group. The primary endpoint was all-cause mortality. Secondary endpoints were stroke, major bleeding, reoperation, and endocarditis. Median follow-up was 12.5 years (IQR: 9.3-15.7 years).

Results: At 15 years, actuarial survival after the Ross procedure was 93.1% (95% CI: 89.1%-95.7%), similar to that of the age-, sex-, and race-matched U.S. general population. It was significantly lower after biological AVR (HR: 0.42; 95% CI: 0.23-0.075; P = 0.003) and mechanical AVR (HR: 0.45; 95% CI: 0.26-0.79; P = 0.006). At 15 years, the Ross procedure was associated with a lower cumulative risk of reintervention (P = 0.008) and endocarditis (P = 0.01) than biological AVR. In contrast, at 15 years, the Ross procedure was associated with a higher cumulative incidence of reoperation (P < 0.001) but lower risks of stroke (P = 0.03) and major bleeding (P = 0.016) than mechanical AVR. Thirty-day mortality after valve-related complications was lowest after a reintervention.

Conclusions: In young adults, the Ross procedure is associated with better long-term survival and freedom from valve-related complications compared with prosthetic AVR. This confirms the notion that a living valve substitute in the aortic position translates into improved clinically relevant outcomes.

Keywords: Ross procedure; aortic valve replacement; bioprostheses; mechanical valves.

Publication types

  • Comparative Study

MeSH terms

  • Adolescent
  • Adult
  • Aortic Valve Disease / surgery*
  • Cardiac Surgical Procedures / methods
  • Female
  • Heart Valve Prosthesis
  • Heart Valve Prosthesis Implantation*
  • Humans
  • Male
  • Middle Aged
  • Propensity Score
  • Prosthesis Design
  • Retrospective Studies
  • Time Factors
  • Treatment Outcome
  • Young Adult