Canadian Journal of Cardiology



      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.


      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.
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