Long-Term Outcomes of Ross Procedure versus Mechanical Aortic Valve Replacement: Meta-Analysis of Reconstructed Time-To-Event Data

In the era of lifetime management of aortic valve disease, the Ross procedure emerged as an alternative to prosthetic heart valves for young adults; however, more long-term data are warranted. We performed a meta-analysis of reconstructed time-to-event data to compare long-term outcomes between the Ross procedure and mechanical aortic valve replacement (mAVR) in young adults. PubMed/MEDLINE, EMBASE and GoogleScholar were searched for studies comparing Ross procedure with mAVR that reported mortality/survival rates and/or reoperation rates accompanied by at least one Kaplan-Meier curve for any of the outcomes. Six observational studies (5 with propensity score matching) including 5024 patients (Ross: 1737; mAVR: 3287) met our inclusion criteria. Patients who underwent Ross had a significantly lower risk of mortality in the overall population (HR 0.38, 95%CI 0.30-0.49, P<0.001; median follow-up of 7.2 years) and in the propensity score matched cohorts (HR 0.55, 95%CI 0.42-0.73, P<0.001; median follow-up of 10.2 years); however, the incidence function for the cumulative risk of reoperation was higher for the Ross procedure (HR 1.91, 95%CI 1.36-2.70, P<0.001; median follow-up of 9.3 years). Data from observational studies suggest that the Ross procedure is associated with lower all-cause mortality compared with mAVR; however, there is a higher risk of reoperation. Besides serving as basis to inform patients about benefits and risks involved in this choice, these results call for further randomized clinical trials to determine whether the Ross procedure can achieve its potential benefits in young patients in need of AVR.