The Ross procedure offers several advantages in patients requiring aortic valve replacement
(AVR). However, it is a more complex procedure than a standard AVR. Whether there
is a risk associated with expanding its eligibility and having multiple surgeons performing
this operation remains a matter of debate.
METHODS AND RESULTS
From 2011-2020, 568 Ross procedures were performed by 5 surgeons in 2 Canadian institutions.
The cohort was divided in 5 periods of 100 patients (P1 through P5) per center to
assess efficacy and safety throughout time. The efficacy endpoints were cross-clamp
time, bypass time and aortic regurgitation (AR)>1 at discharge. Safety was assessed
with a cumulative sum analysis (CUSUM) adjusted using the STS score. The mean age
increased throughout the study period (P1: 45±13 years, P2: 47±12 years, P3: 47±12
years, P4: 48±11 years, P5: 53±10 years; p < 0.01) in center 1. The mean STS score
for mortality increased (P1: 0.5 [0.4-0.7], P2: 0.5 [0.4-0.8], P3: 0.6 [0.5-0.8],
P4: 0.7 [0.5-0.9], P5: 0.8 [0.7-1.3]; p < 0.01) between P1 and P5. The cross-clamp
(P1: 194±29 min, P2: 181±24 min, P3: 166±29 min, P4: 147±30 min, P5: 144±22 min) and
bypass times (P1: 225±43 min, P2: 207±33 min, P3: 186±35 min, P4: 165±36 min, P5:
160±29 min) decreased over time (p < 0.01 for both). Two patients were discharged
with AR>1 (1 in P2 and 1 in P5; p=0.76). The CUSUM analysis showed that the risk of
complications decreased after 100 cases (Figure 1). Three patients had a perioperative
myocardial infarction (1 in P4 and 2 in P5; p=0.25) and 3 patients presented a transient
ischemic attack (2 in P1 and 1 in P2; p=0.70). There was a non-statistically significant
decrease in the need for temporary dialysis (P1: 5 patients, P2: 3 patients, P3: 0
patient, P4: 1 patient, P5: 1 patient; p=0.08). A similar trend was observed in terms
of reintervention for bleeding (P1: 5 patients, P2: 1 patient, P3: 0 patient, P4:
2 patients, P5: 0 patient; p=0.10). The perioperative outcomes did not differ between
centers. Two patients died within 30-days, both during P1 (p=0.20). There was no perioperative
death in center 2. The overall mortality was 0.4%, (O/E ratio=0.24).
In dedicated programs, the learning curve for the Ross procedure is ≈70 cases. Following
this initial phase, nor the addition of other experienced surgeon or increased patient
comorbidities had a significant impact on safety and efficacy. Overall mortality remained
lower than predicted.