The Ross procedure in the young: evidence from multicentre registries.

Abstract

In this issue of The European Journal of Cardio-Thoracic Surgery, Sievers et al. [1] from the German Ross Registry present an updated report on long-term clinical outcomes in the young adult population. The article is the last one of a series of important publications from what originally was the German-Dutch Ross Registry, which set out in 2002 to prospectively collect clinical outcomes in patients having pulmonary autograft valve (or root) replacement from 12 Cardiac Units [2]. The Registry also added retrospective data related to the Ross procedure performed in the same centres between 1988 and 2001 [2] and, starting with 2009, has periodically generated a wealth of information regarding the Ross procedure in over 2000 subjects. The history of multicentre Ross registries is quite long, dating back to the International Ross Registry originally managed by Oury et al. [3]. In spite of the honest effort to provide solid evidence for the outcome of this challenging procedure starting in the mid 1990s, when worldwide enthusiasm for the pulmonary autograft reached its climax, completeness of the database information hardly ever reached 70% of patients [3]. After a couple of initial reports, the International Registry vanished and so did much of the enthusiasm for the Ross procedure, especially in North America [4]. Other attempts were made by the Spanish Registry, which produced a single short-term report on a relatively small patient population in 2003 [5] and by the Dutch Ross Study Group, which also generated a single mid-term report on a more sizable population in 2002 [6] and eventually joined forces with the German centres. Therefore, the international scientific community is deeply indebted to the German (-Dutch) Ross Registry for having, in a more recent era, overcome the historical limitations of prior multicentre experience and for the first time provided solid evidence on early, mid-term and, now, late outcomes after the Ross procedure. The phenomenal effort in keeping one such database alive and updated is well known to many of us who have also faced this challenge [7]. There follows an understanding of the inability to keep all the original Units devoted to this effort, due to a variety of reasons, including lack of follow-up, regulatory issues etc. [1]. In general, the lack of follow-up on such highly selected patients, undergoing technically demanding procedures, portends unsatisfactory outcomes or changes in institutional policies, which are in turn due to untoward results. This has been the case after the excessively confident embrace of this procedure witnessed in Europe and North America in the 1990s, then followed by the equally unjustified censure of the Ross procedure in more recent years [4, 8]. While we confidently await the reunion of the ‘Dutch limb’ of the Registry to the remaining 8 German Units, some inferences on the emerging long-term outcomes can certainly be drawn from the current study. This is the first report where technical modifications to the Ross root replacement procedure, namely root support, appear to lose any protective effect against late autograft dilatation and failure, as originally suggested [2]. Although heterogeneity of root support techniques and shorter follow-up when compared with unsupported autograft root replacement might have influenced this finding, the result causes some concern. Furthermore, even the subcoronary grafting technique, which has been recognized as the safest procedure in very experienced hands, in terms of prevention of autograft dysfunction [2], is not associated with significantly lower freedom from reoperation, even though the Kaplan–Meier curve profile is distinct from those of unsupported and supported autograft roots [1]. This represents worrisome news for all those who have fostered technical adjustments with the hopes of overcoming the limitations of the Ross procedure in the very longterm follow-up. Nonetheless, an overall freedom from autograft reoperation of nearly 83% at 15 years must be considered with satisfaction when looking at the typical age group undergoing the Ross procedure in the German Ross Registry. Indeed, patients between 40 and 60 years of age at the time of aortic valve replacement, although representing a limited proportion of adults in need for aortic valve surgery, are those in whom standard replacement options, to date, continue to have poor outcomes due to premature mortality and accelerated rate of structural deterioration [9, 10]. Even though the Ross operation has been performed in highly select aortic valve disease patients, as correctly stated by the authors, still it must be emphasized that it currently is the single cardiac surgical intervention shown to afford long-term survival identical to the healthy age-matched population [2]. Therefore, while bioprosthetic valve replacement in patients over 60 certainly offers a more favourable outlook when compared with the Ross procedure, particularly in the era of transcatheter valvein-valve implantation, the present update of the German Ross