Ross Procedure Making a Comeback in Aortic Valve Disease

The Ross procedure, which can be used to treat young people with severe aortic valve disease, has seen wide swings in popularity over the years, but now, with consistent data on long-term survival and valve durability, numbers are steadily climbing again.

The 20-year survival rate was more than 90% in a single-center study of 252 people who had undergone the Ross procedure for aortic valve disease, according to new data presented by Varun Shetty, MBBS, from the Narayana Institute of Cardiac Sciences in Bengaluru, India, at the Society of Thoracic Surgeons (STS) annual meeting in Los Angeles.

Shetty presented the findings that also showed the vast majority of patients (87%) did not need another surgery during that time. The main reluctance to use the procedure has been related to concerns about the durability of the results and the possibility that young patients would need another operation.

With the Ross procedure, the diseased aortic valve is replaced with the patient’s own healthy pulmonary valve and the pulmonary valve is replaced with donor tissue. The intricate operation can take twice as long as mechanical aortic valve replacements.

Complex Operation Has Advantages

But Shetty’s team found that survival rates were 95.8% at 5 years, 94.3% at 10 years, 93.3% at 15 years, and 90.3% at 20 years. 

And “freedom from aortic regurgitation was 95.1%, 92.2%, 87.7%, and 84.5% at 5, 10, 15, and 20 years, respectively,” the researchers report. Freedom from pulmonary regurgitation was lower: 97.0% at 5 years, 83.6% at 10 years, 79.7% at 15 years, and 75.1% at 20 years.

Because the Ross procedure uses living tissue, it can avert the need for anticoagulation medication and allow the valves to grow along with a growing child.

Those who undergo the procedure also have fewer bleeding complications and fewer problems “related to infection of their valves,” Shetty said.

His institution, where the study was conducted, performs 30-40 Ross procedures a year, which is the highest volume in India. The procedure takes a certain skillset; it is typically performed on patients as young as 5 years up to about 50 years — depending on comorbidities — but it can also be performed on infants.

Averts Need for Anticoagulation

“For us, it’s as safe as doing a straightforward aortic valve replacement,” Shetty said, although he acknowledged that the risk-benefit analysis would be different at a low-volume center. The safety of the Ross procedure, the low rates of reintervention, and the lack of a need for anticoagulants are particularly important in India, because if a heart procedure leads to complications, subsequent healthcare access can be very difficult, especially in the remote areas of the country. 

Studies like Shetty’s help build confidence in the safety and long-term durability of the procedure, said S. Chris Malaisrie, MD, a cardiac surgeon and professor of surgery at Northwestern Medicine, which is affiliated with the Northwestern University Feinberg School of Medicine, Chicago. 

Ross Procedures Rising in the United States

The Ross procedure is ” definitely making a comeback,” he said. In 2013, there were 66 Ross procedures; that jumped to 531 in 2023, according to STS tracking of the procedure, which is a sevenfold increase.

With the growing number of patients with aortic stenosis, “I think the trend is going to continue,” Malaisrie said.

The Ross procedure experienced a surge in the late 1990s, but numbers dropped in the 2000s and fell to fewer than 100 per year in the United States for reasons that included concerns about whether it was as safe as a mechanical aortic valve replacement and questions about durability, he explained.

But now, with better techniques for the procedure and better perioperative care, “we’ve reduced perioperative mortality. In my hands, risk of death during surgery is well [below] 1%,” he reported.

The data show that survival with the Ross procedure is superior to that with other aortic valve replacements, there are fewer valve-related complications, and “durability for the Ross is pretty good in experienced hands,” Malaisrie explained when he spoke during another STS conference session, adding that the procedure is the best choice for young adults who have bicuspid aortic valve stenosis.

However, “the procedure is complex. You need enough volume to establish enough experience,” he cautioned.

And there are situations in which the Ross procedure is not appropriate, such as when the aortic valve is repairable.

“In aortic stenosis, the valve is not repairable, but when you have aortic regurgitation — leaky aortic valve — those patients should be repaired,” Malaisrie said.

Shetty reports no relevant financial relationships. Malaisrie reports relationships with Artivion, AtriCure Inc., Edwards Lifesciences, Medtronic, and Terumo Aortic.