Ross procedure associated with better long-term survival vs. mechanical, biological AVR
Click Here to Manage Email Alerts
The Ross procedure for aortic valve replacement was associated with better long-term survival compared with biological and mechanical AVR, researchers reported.
In addition, according to new long-term data published in the Journal of the American College of Cardiology, compared with biological AVR, the Ross procedure was associated with lower risk for reintervention and endocarditis, and compared with mechanical AVR, the Ross procedure was associated with higher risk for reintervention but lower risk for stroke and bleeding.
“Not only was survival better than after biological or mechanical aortic valve replacement, it was also identical to the matched U.S. general population. To this day, this is the only operation that has ever been shown to restore survival after aortic valve replacement in young adults,” Ismail El-Hamamsy, MD, PhD, Mount Sinai Randall B. Griepp Professor of Cardiovascular Surgery at the Icahn School of Medicine at Mount Sinai and director of aortic surgery for the Mount Sinai Health System, said in a press release. “This is a huge deal because it demonstrates the impact of valve choice in the long term. However, there is an important word of caution: The Ross procedure is a more complex operation and should only be performed in Ross centers of excellence. When done in that setting, this represents a major breakthrough for young patients with aortic valve disease, including young women contemplating pregnancy.”
For this analysis, researchers queried California and New York databases for patients aged 18 to 50 years who underwent surgical AVR using pulmonary autograft (Ross procedure), biological valves or mechanical valves from 1997 to 2014. Individuals were excluded if they had one or more concomitant procedures, reoperations, infective endocarditis, IV drug use, hemodialysis or out-of-state residency. Participants were propensity-matched, resulting in three groups of 434 patients.
The primary endpoint was all-cause mortality. Secondary endpoints included stroke, major bleeding, reoperation and endocarditis. Median follow-up was 12.5 years.
Ross vs. biological vs. mechanical AVR
Before propensity matching, researchers noted that individuals who underwent the Ross procedure were younger and with fewer comorbidities. After propensity matching, there were no differences in patient demographic characteristics or comorbidities.
Thirty-day mortality occurred in 0.23% of patients who underwent the Ross procedure, 0.69% of the biological AVR group and 0.69% of the mechanical AVR group (P = .71).
Researchers reported that the Ross procedure was associated with lower risk for mortality at 15 years compared with biological AVR (HR = 0.42; 95% CI, 0.23-0.75; P = .003) and mechanical AVR (HR = 0.45; 95% CI, 0.26-0.79; P = .006), and was similar to the age-, sex- and race-matched general U.S. population (HR = 0.97; 95% CI, 0.94-1.01).
For the secondary outcome of stroke, the researchers observed no difference in 15-year risk between those who underwent the Ross procedure compared with biological AVR (HR = 0.61; 95% CI, 0.24-1.57; P = .3); however, stroke risk after the Ross procedure was lower compared with mechanical AVR (HR = 0.37; 95% CI, 0.16-0.89; P = .03).
In addition, the risk for major bleeding was not different between the Ross procedure or biological AVR (HR = 0.5; 95% CI, 0.19-1.32; P = .16) and was lower for the Ross procedure compared with mechanical AVR (HR = 0.32; 95% CI, 0.13-0.81; P = .016).
The researchers observed lower risk for reoperation with the Ross procedure compared with biological AVR (HR = 0.63; 95% CI, 0.45-088; P = .008); however, the risk for reoperation was higher with the Ross procedure compared with mechanical AVR (HR = 2.4; 95% CI, 1.5-3.8; P = .0002).
For the secondary endpoint of endocarditis, the Ross procedure was associated with lower risk compared with biological AVR (HR = 0.37; 95% CI, 0.17-0.8; P = .012), and similar risk compared with mechanical AVR (HR = 0.61; 95% CI, 0.25-1.5; P = .61).
“This study demonstrates that while there is a definite risk of reoperation after the Ross procedure, the associated risk is low. In other words, this should be seen as a bump on the road, rather than the end of the road. In contrast, if patients suffer a stroke, hemorrhage or infection, the consequences are much more dire,” El-Hamamsy said in the release. “Patients should be given all this data so they can make truly informed decisions about these major life events. Ultimately ... the Ross procedure is associated with better survival and fewer complications.”
Benefits of a ‘living’ valve
In a related editorial, Magdi H. Yacoub, MBChB, professor of cardiothoracic surgery at the National Heart and Lung Institute of Imperial College London and founder and director of research at the Harefield Heart Science Centre in London, wrote: “The Ross operation outperformed the other two substitutes in all [endpoints], except for the rate of reoperation. As expected, long-term survival after the Ross operation was the only survival that matched that of the general population,” Yacoub wrote. “This confirms previous studies and strengthens the notion that a ‘living’ valve substitute can prolong life, presumably by enhancing ventriculo-arterial coupling as well as other mechanisms.
“With regard to the rate of reoperations, this was initially higher after the Ross operation; however, the mortality of the reoperation, in this cohort, was exceptionally low,” Yacoub wrote. “An unexpected finding was the steadily rising rate of reoperation after prosthetic valve replacement.”
References:
- The Ross procedure leads to improved survival in adults undergoing aortic valve surgery. https://www.newswise.com/articles/the-ross-procedure-leads-to-improved-survival-in-adults-undergoing-aortic-valve-surgery. Published Feb. 21, 2022. Accessed Feb. 21, 2022.
- Yacoub MH. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2021.12.014.
Collapse
Read more about
Click Here to Manage Email Alerts