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The Ross Procedure after Prior Aortic Valve Intervention: Outcomes from the North American Ross Consortium Database
Kyle A. McCullough3, Cody W. Dorton3, Taylor Pickering3, John B. Eisenga3, Tanushree Prasad3, Mary C. Parro3, Emma B. Galvanek3, Bonnie D. Ostergren3, Sarah Hale3, J. Michael DiMaio3, *Justin Schaffer3, Scott C. DeRoo1, Christopher Mehta2, *Christopher Burke1, S. Chris Malaisrie2, Nimesh D. Desai4, William Brinkman3, *Katherine Harrington3
1University of Washington, Seattle, Washington, United States, 2Northwestern University, Chicago, Illinois, United States, 3Baylor Scott & White The Heart Hospital Plano, Plano, Texas, United States, 4University of Pennsylvania, Philadelphia, Pennsylvania, United States
Objective: Excellent results for the Ross procedure have been demonstrated in selected, single-center series. Outcomes for higher-risk patients, including those with prior aortic valve intervention, have not been well-described. A prospective, multicenter database has been created to study such outcomes.
Methods: This is an analysis of all adult recipients of the Ross procedure between 1994 and 2024 at four high volume aortic centers comprising the North American Ross Consortium (NARC). Patients with prior aortic valve intervention (AVI), including balloon aortic valvuloplasty or aortic valve repair/replacement, were compared to those with no prior aortic valve intervention (native aortic valve (NAV)). The primary outcome was operative mortality. Secondary outcomes included perioperative outcomes. Descriptive statistics were used in the analysis. Normal continuous variables are presented as mean (standard deviation) while non-normal continuous variables are presented as median [interquartile range]. Categorical variables are presented as counts and percentages. The Chi-square test or Fisher's exact test was applied to categorical variables. The Kaplan-Meier method was used for survival estimate curves, which were compared using log-rank tests. A significance level of 5% was used for all statistical tests.
Results: Total cohort size was 447 patients. Thirty-four (7.6%) had a prior AVI, while 413 (92.4%) had a NAV. Median age at surgery was 32 years for the AVI group and 42 for the NAV group (p<0.01). Male sex, body mass index, smoking status, and comorbid conditions were similar between groups, except for prevalence of hypertension (14.7% vs 36.8%, p<0.01) and endocarditis (active: 8.8% vs 1.7%, p =0.03) (Table 1). Urgency of surgery, aortic diameters and ejection fracture were also similar. Cardiopulmonary bypass times were significantly longer for the AVI group, 230 min vs 205 min, p<0.01, as were cross-clamp times, 197 min vs 181 min, p=0.01 (Table 2). Postoperative length of stay was 7 vs 5 days, p=0.11. Rates of reoperation for bleeding were similar: 2.9% vs 3.9%, p=0.61. Non-significant differences in perioperative morbidities including renal failure requiring dialysis, prolonged ventilation, stroke, atrial fibrillation, myocardial infarction and deep sternal wound infection were seen. Rates of pacemaker implantation (8.8% vs 3.7%, p=0.28) and operative mortality were higher in the AVI group (2.9% vs 1.7%, p=0.47), though neither reached significance.
Conclusions: Non-significant but higher rates of pacemaker implantation and operative mortality were seen in the AVI group. While the Ross procedure can be safely performed in such patients, early analysis of this population using NARC data suggests elevated operative risk. Future study and greater numbers are needed to more fully assess Ross procedure outcomes in patients with prior aortic valve intervention.
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