Ross Procedure Research Articles

The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement.

The Ross procedure is gaining recognition as a significant option for aortic valve replacement (AVR), and is particularly beneficial in specific patient groups. Although categorized as a class IIb recommendation in the 2020 American College of Cardiology (ACC)/American Heart Association (AHA), and the European Society of Cardiology (ESC) management guidelines on valvular heart disease, recent studies bolster its credibility. Research, including a propensity-matched study, underlines the Ross procedure's association with enhanced long-term survival and reduced adverse valve-related events compared to other AVR types. This positions the Ross procedure as a primary option for AVR in young and middle-aged adults within specialized centers, and potentially the only choice for children and infants requiring AVR. This review meticulously examines the Ross procedure, covering historical perspectives, surgical techniques, imaging, and outcomes, including hemodynamic performance and quality of life, especially focusing on pediatric and young adult patients. It explores contemporary techniques and innovations like minimally invasive approaches and tissue engineering, underscoring ongoing research and future directions. A summarization of comparative studies and meta-analyses reiterates the Ross procedure's superior long-term outcomes, valve durability, and preservation of the left ventricular function, accentuating the crucial role of patient selection and risk stratification, and pinpointing areas for future research.

Long-term autograft dilation and durability after the Ross procedure are similar in infants, children, and adolescents with primary aortic stenosis

BackgroundAutograft durability and remodeling are thought to be superior in younger pediatric patients after the Ross operation. We sought to delineate the fate of autografts across the pediatric age spectrum in patients with primary aortic stenosis (AS). MethodsWe retrospectively reviewed patients age ≤18 years with primary AS who underwent the Ross operation between 1993 and 2020. Patients were categorized by age. The primary endpoint was autograft dimensional change, and secondary endpoints were severe neo-aortic insufficiency (AI) and autograft reintervention. ResultsA total of 119 patients underwent the Ross operation, including 37 (31.1%) in group I (age <18 months), 24 (20.2%) in group II (age 18 months-8 years), and 58 (48.7%) in group III (age 8-18 years). All groups exhibited similar annular growth rates within the first 5 postoperative years, followed by a collective decrease in annulus growth rates from year 5 to year 10. Group III experienced rapid sinus dilation in the first 5 years, followed by stabilization of the sinus z-score from year 5 to year 10, whereas groups I and II demonstrated stable sinus z-scores over 10 years. There were 4 early deaths (3.4%) and 2 late deaths (1.7%) at a median follow-up of 8.1 years (range, 0.01-26.3 years). At 15 years, the incidences of severe neo-AI (0.0 ± 0.0% vs 0.0 ± 0.0% vs 3.9 ± 3.9%; P = .52) and autograft reintervention (8.4 ± 6.0% vs 0.0 ± 0.0% vs 2.4 ± 2.4%; P = .47) were similar in the 3 groups. ConclusionsAge at the time of Ross operation for primary AS does not influence long-term autograft remodeling or durability. Other physiologic or technical factors are likely greater determinants of autograft fate.

Autologous inclusion technique versus Dacron inclusion technique in modified Ross surgery in adults: a retrospective single-center study

The Ross procedure has been shown to have excellent long-term outcomes. However, pulmonary autografts remain at risk of dilation in the long-term period. Therefore, the autologous inclusion technique (AIT) and the Dacron inclusion technique (DIT) have been developed. No direct comparison up to date has been reported of these two techniques.Aim: To compare immediate and medium-term results performing various modified techniques of the Ross operation.Material and Methods. The following retrospective study included 43 patients (AIT: 22; DIT: 21) aged 18 years and older with an aortic valve (AV) pathology who underwent modified Ross procedures (AIT and DIT) from January 2014 to December 2019, performed by a single surgeon. The main endpoints were: in-hospital mortality, postoperative AV pressure gradients, time of myocardial ischemia and cardiopulmonary bypass, postoperative complications (resternotomy due to bleeding, perioperative myocardial infarction, stroke, sternal infection, conduction disorder requiring implantation of a permanent pacemaker, acute renal failure requiring hemodialysis) and mid-term outcomes (freedom from reoperation, freedom from aortic dilatation ≥ 5 cm). The median follow-up period was 23 (12–68) months.Results. The main indication for surgery was aortic regurgitation in 32 patients (74.4%). Bicuspid aortic valve was diagnosed in 29 (67.4%) patients. There were 33 (76.7%) males with an average age of 40 ± 11.7 years. There were no lethal outcomes in both groups. There was also no significant difference in postoperative complications. The peak and mean gradients on the AV were significantly lower in the AIT group than in the DIT group (6 and 4 mmHg vs 8 and 7 mmHg, p = 0.04). Five-year overall survival, freedom from reoperation on AV and PV, and freedom from dilatation of the ascending aorta ≥ 5 cm after modified Ross operation were 97.4%, 100%, and 100%, respectively. There was no statistically significant difference between groups in terms of overall survival (p = 0.66).Conclusion. Both techniques, autologous inclusion and Dacron inclusion, provide excellent immediate and mid-term outcomes in terms of overall survival, freedom from reoperation and freedom from aortic dilation

The 2F technique: A novel approach in the Ross procedure

The 2F technique: A novel approach in the Ross procedure

Contemporary Surgical Approaches in Pediatric Aortic Valve Surgery: A Retrospective Comparison of Three Techniques

Background: Congenital aortic valve (AV) disease is viewed in 2% of the population and in 20 out of 1000 neonates are presented with bicuspid configuration. Treatment of the congenital AV diseases requires multiple interventions. The ultimate goal is to provide adequate close to physiological left ventricle outflow and minimization of regurgitation. The optimal operative management of AV disease in children and young adults remains controversial. AV neocuspidization with glutaraldehyde‐treated autologous pericardium may be a satisfactory alternative in pediatric cardiac surgery.Objectives: The data of the AVNeo procedure results enable a comparative analysis of various AV reconstructive approaches in the pediatric cohort. In this article, we present the comparative study of various techniques in pediatric AV surgery, including the immediate and midterm outcomes of AVNeo, commissurotomy with aortic leaflet augmentation using pericardial patch (“free style” technique), and Ross procedure.Study Design: We conducted a retrospective analysis of the early and midterm results of surgical AV disease treatment of 44 children in 5 cardiac surgery centers from 2014 to 2022. The patients were divided into 3 groups: group I: glutaraldehyde‐treated autologous pericardium AVNeo (n = 12), group II: “free style” technique (n = 10), and group III: Ross procedure (n = 22). We described the immediate and midterm outcomes. The study design was approved by the ethics committees of the participating centers.Results: A total of 44 children after surgical treatment of the AV disease in 5 cardiac surgery centers were included in the study and were grouped as group I: AVNeo (n = 12), group II: “free style” technique (n = 10), and group III: Ross procedure (n = 22). The median follow‐up period was 57 ± 23.8 months. In‐hospital mortality was 4.5% (n = 2). In the midterm follow‐up, the peak pressure gradient was 18.45 ± 4.63 mmHg for group I and 8.9 ± 1.6 mmHg for group III (p = 0.00001), respectively. The cumulative freedom from reoperations was 100%, 30%, and 95.2% for 40 months of follow‐up and 100%, 30%, and 83.4% for 70 months of follow‐up in I, II, and III groups, respectively. No cases of midterm mortality were detected in all groups.Conclusion: The AV neocuspidization with glutaraldehyde‐treated autologous pericardium has an enormous advantage in pediatric AV surgery, significantly surpassing the freedom from resurgery of repair procedures and having comparable results with the Ross procedure in the midterm follow‐up.

Aortic insufficiency following balloon aortic valvuloplasty does not impact long-term autograft durability after the Ross procedure

ObjectivePreoperative aortic insufficiency (AI) is associated with inferior autograft durability after the Ross procedure. However, many patients with aortic stenosis (AS) undergo balloon aortic valvuloplasty (BAV) early and present with longstanding AI before Ross. We studied how BAV and subsequent valvular pathology impacts autograft durability. MethodsPatients undergoing the Ross operation from 1993 to 2020 were identified. Those who underwent BAV before Ross were compared with patients who did not undergo BAV and underwent Ross for predominant AI (AI group) or AS (AS group). Those who underwent previous open surgical aortic valve intervention were excluded. Primary outcome of interest was autograft failure, defined as a composite of autograft reintervention or severe insufficiency. ResultsA total of 198 patients were included. Seventy-nine (39.9%) underwent BAV and subsequently underwent the Ross for predominant AI (45.6%) or AS (54.4%). Of patients who did not undergo BAV, 66 (33.3%) presented with predominant AI and 53 (26.8%) with AS. Freedom from autograft failure at 15 years was 90%, 92%, and 62% in BAV, AS, and AI groups, respectively. The AI group was at significantly increased risk of long-term autograft failure (hazard ratio, 5.6; P = .01), whereas the AS and BAV groups had similar, low risk (hazard ratio, 1.1; P = .91). Autograft durability was similar among patients who received BAV and presented with AS or AI before the Ross (P = .84). ConclusionsBAV before the Ross procedure is common in patients with AS. These patients have excellent long-term autograft durability regardless of preoperative valvular pathology and should strongly be considered for the Ross operation.

Reoperations after Ross procedure: a retrospective study

Aim. To analyze the immediate outcomes of reinterventions after Ross procedure.Material and methods. From April 2009 to December 2022, 224 Ross operations in adults were performed at the Federal Center for Cardiovascular Surgery. The retrospective study included 17 patients who required repeated interventions (14 men/3 women). The mean age of the patients was 38±11 years, with a minimum age of 21 and a maximum of 54 years. A history of infective endocarditis was revealed in 4 (23,5%) patients, hypertension — in 3 (17,6%) patients. Of the 17 included patients, 15 patients underwent the classic Ross operation ("full root replacement"), while 2 — a modified technique (1 — wrapping with aorta, 1 — wrapping with a Dacron graft). Annulus enhancement was previously performed in 3 patients.Results. Interventions on the pulmonary autograft and homograft were performed in 16 and 4 cases, respectively. The main indication for pulmonary autograft intervention was aortic regurgitation in 15 cases, and neoaortic aneurysm in 14 cases. In 3 patients, there was pulmonary homograft stenosis, while in 1 case — thrombosis. Two patients required interventions on other valves: 1 — mitral valve stenosis, 1 — severe tricuspid regurgitation. Mean reoperation, cardiopulmonary bypass and myocardial ischemia time were 289±62, 126±35 and 98±22 min, respectively. Combined interventions were performed in 6 cases. David valve-sparing procedure was performed in 9 patients, Bentall-de Bono technique — in 3, aortic valve repair — in 2, mechanical aortic valve replacement — in 2, supracoronary ascending aorta replacement — in 2, pulmonary homograft replacement — in 2, pulmonary homograft thrombectomy — in 1, pulmonary homograft repair — in 1 patient, mitral valve replacement — in 1 patient, tricuspid valve repair — in 1 patient. One patient required resternotomy for bleeding. There were no postoperative complications (perioperative myocardial infarction, acute kidney injury, stroke, sternal infection, cardiac tamponade) and deaths. The median length of stay in intensive care unit was 21 [16-23] hours.Conclusion. Reoperations after the Ross procedure may be required for different pathologies, but all can be performed surgically with a high safety in experienced operator.

IMMEDIATE AND LONG-TERM RESULTS OF MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT: SINGLE CENTER RETROSPECTIVE STUDY

HighlightsWe have conducted a retrospective analysis of patients who underwent minimally invasive aortic valve replacement, and evaluated immediate and long-term results of the surgery. AbstractAim. To study the immediate and long-term results of minimally invasive aortic valve (AV) replacement.Methods. The retrospective study included 208 patients with AV stenosis undergoing minimally invasive aortic valve replacement in the period from 2010 to 2019. The ratio of men to women was 1:1. The mean age of the patients was 63 (58–68) years old, with the minimum age being 29 years and the maximum being 81 years. The median follow-up period was 45.5 (11–68) months. Endpoints were as follows: hospital mortality, postoperative complications, long-term outcome (long-term survival, freedom from reoperation). Inclusion criteria were as follows: patients aged 18 years and older undergoing minimally invasive aortic valve replacement. Exclusion criteria were as follows: AVNeo, Ross procedure and AV replacement with aortic homograft, combined interventions (except for intervention on the ascending aorta), and standard access site.Results. The majority of patients (199 (95.7%) underwent “J”-shaped ministernotomy through the III-IV intercostal space. As a part of the combined intervention, ascending aorta replacement was performed in 6 (2.9%) patients. The duration of cardiopulmonary bypass and aortic cross-clamping was 91 (78–106) min and 68 (60–78) min, respectively. Due to conduction disorders, implantation of a pacemaker was performed in 5 (2.4%) patients, stroke was diagnosed in 1 (0.5%) patient, resternotomy for bleeding was performed in 4 (1.9%) patients, cardiac tamponade in 2 (1 %) patients, sternal infection was found in 1 (0.5%) patient. There were no complications such as AKI, perioperative MI, or hospital mortality in any patient. Five- and ten-year survival after surgical treatment of patients was 88.2% and 80.5%, respectively. Five- and ten-year freedom from reoperation on AV was 96.2% and 96.2%.Conclusions. Minimally invasive AV replacement is a measurable procedure with negligible complication rates. Minimally invasive aortic valve replacement has shown its effectiveness in the long-term period with acceptable rates of survival and freedom from reoperation.

Discussion to: Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure

Discussion to: Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure

Dissemination and implementation analysis of the Ross procedure in adults: time to update the guidelines?

BackgroundThe science of dissemination and implementation (D&I) aims to improve the quality and effectiveness of care by addressing the challenges of incorporating research and evidence-based practice into routine clinical practice. This lens of D&I has challenged the interpretation and incorporation of data, noting that failure of a given therapy may not reflect lack of efficacy, but instead reflect an imperfect implementation. The aim of this manuscript is to review the influence of the Ross procedure’s historical context on its D&I.MethodsA contextual baseline of the Ross procedure was defined from the procedure’s original description in the literature to major publications since the 2017 valvular heart disease guidelines. D&I evaluation was conducted using the Consolidated Framework for Implementation Research (CFIR), using constructs from each of the five respective domains to define the main determinants.ResultsEach of the five CFIR domains appears to be correlated with a factor influencing the Ross procedure’s varied history of enthusiasm and acceptance. The complex nature of Ross required adaptation for optimization, with a strong correlation of center volume on outcomes that were not considered in non-contemporary studies. Outcomes later published from those studies influenced social and cultural contexts within the aortic surgery community, and led to further organizational uncertainty, resulting in slow guideline incorporation.ConclusionsThe D&I of the Ross procedure was a result of inadequate appreciation of technical complexity, effect of patient selection, and complex aortic surgery experience, resulting in dismissal of an efficacious procedure due to a misunderstanding of effectiveness.

Truncal valve repair in an adolescent with severe annular dilatation

Approximately 20% of patients with truncus arteriosus might need a truncal valve procedure within 20 years after anatomical repair due to regurgitation. These patients commonly develop valve regurgitation due to root dilatation with a sufficient amount of good quality valvular tissue. Thus, the reduction of the truncal annulus is the single most important factor to achieve durable repair, especially in patients in whom the Ross procedure is not an option.

Is there still role for the Ross procedure?

The ideal aortic valve substitute for young and middle-aged adults with aortic valve disease is still debated. The Ross procedure (pulmonary autograft replacement) is the only operation that allows replacement of the diseased aortic valve with a living substitute. During the years, the use of this procedure has declined significantly due to concerns over increased intraoperative risk and especially potential long-term failure of the operation. However, several recent publications have shown that, after appropriate learning curve and in specialized centers, the Ross procedure can be performed safely in appropriately selected patients. Moreover, comparative studies suggest that the Ross procedure is associated with better long-term outcomes compared to conventional aortic valve replacement in young and middle-aged adults.

Outcomes of aortic valve repair in children stratified by complexity: Which outcome for which lesion?

ObjectiveAortic valvuloplasty frequency has significantly increased over the past 15 years. Surgical repair varies in complexity depending on valvular lesions. Our aim is to report results on the whole spectrum of aortic valvuloplasty techniques. MethodsAll children who consecutively underwent aortic valvuloplasty for aortic stenosis and/or aortic insufficiency between January 2006 and December 2020 at Necker Sick Children's Hospital (Paris, France) were included in a retrospective cohort study. Aortic valvuloplasty techniques were classified into 3 difficulty levels: (1) simple repair, corresponding to commissurotomy and/or shaving in aortic stenosis (AS) in neonates (group 1) and children >1 month (group 2); (2) intermediate-complexity repair, corresponding to commissuroplasty, leaflet resuspension, and fenestration closure in aortic insufficiency (leaflet prolapse in connective tissue disease, isolated leaflet prolapse and Laubry–Pezzi groups); and (3) complex repair requiring a pericardial patch to restore a functional aortic valve in mixed aortic valve disease (bicuspidization with neocommissure and cusp extension groups). ResultsDuring the study period, 324 children underwent aortic valvuloplasty. Survival and freedom from aortic valve reintervention at 10 years were, respectively, 86.1% and 50.9% in neonates with AS, 95.2% and 71.7% in children >1 month with AS, 93.8% and 79.5% in leaflet prolapse in connective tissue disease, 97.7% and 91.9% in isolated leaflet prolapse, 100% and 88% in those with Laubry–Pezzi syndrome, 97.4% and 84.8% in bicuspidization with neocommissure, and 100% and 54.2% in the cusp extension. ConclusionsDurability of aortic valvuloplasty techniques is satisfactory and offers the possibility to delay the Ross procedure, regardless of the lesion's complexity.

Bioprosthetic Valves for Lifetime Management of Aortic Stenosis: Pearls and Pitfalls.

This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons.

Ross procedure or mechanical aortic valve, which is the best lifetime option for an 18-year-old? A decision analysis

Objective(s)Identifying the optimal solution for young adults requiring aortic valve replacement (AVR) is challenging, given the variety of options and their lifetime complication risks, impacts on quality of life, and costs. Decision analytic techniques make comparisons incorporating these measures. We evaluated lifetime valve-related outcomes of mechanical aortic valve replacement (mAVR) versus the Ross procedure (Ross) using decision tree microsimulations modeling. MethodsTransition probabilities, utilities, and costs derived from published reports were entered into a Markov model decision tree to explore progression between health states for hypothetical 18-year-old patients. In total, 20,000 Monte Carlo microsimulations were performed to model mortality, quality-adjusted-life-years (QALYs), and health care costs. The incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analyses was performed to identify transition probabilities at which the preferred strategy switched from baseline. ResultsFrom modeling, average 20-year mortality was 16.3% and 23.2% for Ross and mAVR, respectively. Average 20-year freedom from stroke and major bleeding was 98.6% and 94.6% for Ross, and 90.0% and 82.2% for mAVR, respectively. Average individual lifetime (60 postoperative years) utility (28.3 vs 23.5 QALYs) and cost ($54,233 vs $507,240) favored Ross over mAVR. The average ICER demonstrated that each QALY would cost $95,345 more for mAVR. Sensitivity analysis revealed late annual probabilities of autograft/left ventricular outflow tract disease and homograft/right ventricular outflow tract disease after Ross, and late death after mAVR, to be important ICER determinants. ConclusionsOur modeling suggests that Ross is preferred to mAVR, with superior freedom from valve-related morbidity and mortality, and improved cost-utility for young adults requiring aortic valve surgery.

Ross procedure with personalized external aortic root support

The Ross–Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in the aortic position to replace the malfunctioning aortic valve and a homograft is implanted in the pulmonary position. To prevent autograft dilatation, a Personalized External Aortic Root Support prosthesis is included in the proximal autograft anastomosis and wrapped around the ascending aorta. The aorta is transected transversely, the aortic valve is resected, and the coronary arteries are mobilized and cut out of the sinuses, leaving a rim. The pulmonary autograft is harvested by transecting the pulmonary artery and part of the right ventricular outflow tract. The autograft is approximated to the aortic root and inverted inside the ventricle. The proximal anastomosis is performed including the prosthesis between the aortic root and the autograft. The coronary buttons are threaded through appropriately positioned and sized holes in the prosthesis and reimplanted into the autograft. The ascending aorta is appropriately adapted and anastomosed with the distal autograft. When the patient is off cardiopulmonary bypass, the prosthesis can be closed longitudinally and is anchored to the distal aortic adventitia.

Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure

The Ross procedure as treatment for adults with aortic valve disease (AVD) has been the subject of renewed interest. To evaluate the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with AVD. This post hoc analysis of a randomized clinical trial included adult patients (age <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. Ross procedure. The primary end point was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin- and sex-matched general population. Secondary end points were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%). This study found that the Ross procedure provided excellent survival into the third decade postoperatively that was comparable to that in the general population. Long-term freedom from reintervention demonstrated that the Ross procedure may be a durable substitute into late adulthood, showing a delayed but progressive functional decline. isrctn.org Identifier: ISRCTN03530985.

The Longest Reported Outcomes of the Ross Procedure

The Longest Reported Outcomes of the Ross Procedure

Abstract 16917: Ross Procedure versus Biological Aortic Valve Replacement in Adults in a Single Center Setting: A Propensity Score Matched Comparison

Background: Guidelines suggested alternative for middle-aged adults undergoing aortic valve replacement is mechanical prosthesis, followed by the Ross procedure (Ross). However, increasingly more patients receive a biological prosthesis (bio AVR) even in young adult age. Is this practice justified? Objectives: To compare long-term outcomes in a single center after Ross vs bio AVR. Methods: For this retrospective study, we screened 2624 patients 04/2007 - 03/2020. Out of these, 231 received Ross, and 2393 received bio AVR ± CABG or aortic surgery. Exclusion criteria: emergency surgery and concomitant mitral or tricuspid valve surgery. Using 1:1 propensity score 99 matches were paired. Primary end-point was all-cause mortality. Secondary end-point was composite of death, need for repeat intervention, and stroke (MACCE). Median follow-up was 7.5 years (IQR: 4.4 - 10.6 years). Results: Mean age for Ross was 56.2±6.1, and for bio AVR was 56.2±5.9. Actuarial 10-year survival for Ross was 89.3%, but significantly lower for the bio AVR 57.9%. All-cause mortality was significantly lower after the Ross procedure compared to the bio AVR (log rank p&lt;0.001). The MACCE-free survival was significantly better after the Ross procedure (log rank p&lt;0.001). Conclusion: In middle-aged adults undergoing AVR, the Ross procedure was superior over the conventional bio AVR after 10 years F/U. Bio AVR should therefore be avoided in this patient population every time possible. Overall long-term survival after Ross vs bio AVR: MACCE free survival after Ross vs bio AVR:

Drivers of vascular growth and remodeling: A computational framework to promote benign adaptation in the Ross procedure

In the sixties, Dr Donald Ross designed a surgical solution for young patients with aortic valve disease by using the patients’ own pulmonary valve. The Ross procedure is the only aortic valve replacement technique that can restore long-term survival and preserve quality of life. The main failure mode of the Ross procedure is wall dilatation, potentially leading to valve regurgitation and leakage. Dilatation occurs due to the inability of the pulmonary autograft to adapt to the sudden increase in loading when exposing to aortic pressures. Previous experimental data has shown that a permanent external support wrapped around the artery can prevent the acute dilatation of the arterial wall. However, the textile support leads to stress-shielding phenomena due to the loss of mechanical wall compliance. We present a pragmatic and modular computational framework of arterial growth and remodeling predicting the long-term outcomes of cardiovascular tissue adaptation, with and without textile wrapping. The model integrates mean, systolic and diastolic pressures and assumes the resulting wall stresses to drive the biological remodeling rules. Rather than a single mean pressure or stress deviation from the homeostatic state, we demonstrate that only pulsatile stresses can predict available experimental results. Therefore, we suggest that a biodegradable external support could induce benign remodeling in the Ross procedure. Indeed, a biodegradable textile wrapped around the autograft fulfills the trade-off between prevention of acute dilatation on the one hand and recovery of arterial wall compliance on the other hand. After further validation, the computational framework can set the basis for the development of an actual biodegradable external support for the Ross procedure with optimized polymer mechanical properties and degradation behavior.