Long-Term Outcomes Following the Ross Operation: A 22-Year Single Institutional Experience

V. Shetty, P. Narayan, S. Rao, P. Tambrallimath, V. G, D. Shetty
Narayana Health, Bengaluru, Karnataka

Purpose: Ross procedure is an important strategy for addressing aortic valve pathology. However, pulmonary autograft failure over time and development of pulmonary valve stenosis or regurgitation are important concerns(1,2). Aim of this study was to investigate the long-term durability of the Ross procedure and identify factors that contribute to improved outcomes.

Methods: This was a retrospective study on prospectively collected single institutional data spanning from 2001 to 2023. All patients undergoing the Ross procedure during this period were included in the study. Clinical follow-up assessed all-cause mortality, cardiac mortality, and freedom from re-intervention, while echocardiographic follow-up evaluated presence of moderate to severe aortic regurgitation and aortic and pulmonary gradients (mean and peak). Baseline characteristics, operative details, and post-operative outcomes were recorded. Outcomes were analyzed at 5, 10, 15, and 20-year intervals. Age stratification was performed to compare outcomes between patients older than 18 years and those 18 years or younger. Survival rates were reported using Kaplan-Meier curves, and correlations between risk factors and post-operative outcomes were analyzed to identify factors contributing to improved long-term results.

Results: During the study period, 252 patients underwent the Ross procedure, with 186 patients (73.8%) using the mini root replacement technique, and 25 patients (9.9%) using the Dacron-reinforced autograft technique. Three patients (1.2%) underwent the Ross-Konno procedure. Concomitant procedures included ascending aorta replacement in 25 patients (9.9%), hemiarch replacement in 2 patients (0.8%), and septal myectomy in 4 patients (1.6%). The pulmonary valve was replaced with an antibiotic-sterilized cryopreserved homograft from an in-house tissue valve bank in 171 cases (69.2%). In-hospital mortality was 1.9% (n=5). The median follow-up duration was 6.4 years (IQR 0.8, 15 years).
There was no difference in survival and re-intervention rates, but a significantly higher incidence of aortic regurgitation was observed in patients aged 18 years or younger (Figure 1).
Freedom from all-cause mortality was 95.8% at 5 years, 94.3% at 10 years, 93.3% at 15 and 90.3% at 20 years. Freedom from aortic regurgitation was 95.1%,, 92.2%, 87.7% and 84.5% at 5,10,15 and 20 years respectively. Freedom from pulmonary regurgitation was lower at 97%, 83.6%, 79.7% and 75.1% at 5,10,15 and 20 years. Freedom from re-intervention was 94.2%, 91.1%, 88.4% and 86.8% at 20 years (Table 1).

Conclusion: The Ross procedure shows excellent long-term survival and low re-intervention rates and are comparable to surgical aortic valve replacement without necessitating anticoagulation. However, individuals aged 18 years or younger exhibit notably higher rates of aortic regurgitation. Risk factors for late autograft dysfunction include a dilated aortic annulus and ascending aorta.

Identify the source of the funding for this research project: not applicable