Author + information
- aDepartment of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
- bDepartment of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
- ↵∗Address for correspondence:
Dr. Gösta B. Pettersson, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-1, Cleveland, Ohio 44195.
In this issue of the Journal, Buratto et al. (1) at Royal Melbourne Hospital, Australia, present an Australian registry study comparing survival after the Ross procedure with aortic valve replacement using a mechanical valve, and show that survival is better after the Ross procedure.
The authors again stir up the controversy about optimal strategies and options for younger adults who require replacement of their aortic valve. We live in an era when patients want to be active and independent and thus do not want to take anticoagulants for the rest of their lives. This pushes surgeons to try harder to repair rather than replace the valve, and when replacement is necessary, to use a tissue valve prosthesis rather than a mechanical one. It is known that native aortic valve repair is often not perfect, and tissue valve prostheses do not last long in younger patients and require replacement again in 10 to 15 years or less (2). Implantation of a transcatheter valve is now being done in lower-risk patients, and valve-in-valve is offered to almost anyone with a failed tissue prosthesis that is large enough (3). Younger patients say, “I have a tissue valve, and when it fails I will have my next valve from the groin; and when that one fails, I will have another one from the groin.” The feasibility, value, and safety of this strategy remain to be demonstrated.
Donald Ross performed the first Ross procedure in 1967 and over the next 20 years accumulated a series with very good outcomes (4). In the mid-1980s, Stelzer and Elkins (5) introduced the full free-standing root autograft implantation technique, making the operation technically easier, and this modification generated worldwide interest in the Ross procedure as the operation of choice for young adults with aortic valve disease. Every aortic valve surgeon of stature wanted to perform this operation. An enthusiastic group of Ross surgeons met regularly and started the International Registry of the Ross Procedure (6). Within 10 years of this surge, the weaknesses and drawbacks of the operation (high mortality, autograft dilation and valve failure, and failure of the right-sided allograft) became apparent. Most of the cardiology and cardiac surgery communities turned against the Ross procedure as being too high risk and converting a single valve disease into a double valve disease. Consequently, the number of Ross operations diminished rapidly.
At no time was the value of the Ross procedure in children seriously challenged. A few cardiac surgeons treating adults are still committed to and performing Ross operations. The larger series they have presented over the last 15 years demonstrate low mortality and excellent medium-term survival, with the largest series coming from the German Ross Registry, which includes 1,779 procedures (7). These surgeons learned much about the procedure from the surge era and refined their techniques, paying more attention to annulus sizing and support, reintroducing the free-hand subcoronary implantation technique, modifying the full root replacement technique, and adding autograft support using different techniques, such as autologous tissue support (“cylinder in a cylinder”) or even prosthetic material and graft support.
The present series from Australia is equally or even more impressive, with 1 death (0.3%) in 30 days out of 392 Ross operations and 15 (0.8%) deaths out of 1,928 aortic valve replacements with mechanical prostheses (1). This confirms that talented surgeons with appropriate training and commitment can perform the Ross procedure with minimal mortality. Most Ross procedures were performed using the modified inclusion cylinder method. The mean aortic clamp time of 173 ± 22 min is a clear demonstration that the Ross procedure must be done with great care, precision, and perfect myocardial protection. The surgeon who would like to perform the Ross operation should learn it from one of its masters and take advantage of what has been learned about patient selection and implantation techniques to optimize outcomes. Extensive experience with aortic root surgery is required. Over the years much more also has been learned about how to manage autograft and allograft failures with reimplantation, Ross reversal (8), and percutaneous interventions to limit the consequences of these failures.
The paper by Buratto et al. (1) is a registry study with limited availability of clinical variables and follow-up. The study does not provide data on patient selection or the advisability of performing the Ross procedure in patients with unicuspid or bicuspid aortic valves, pure aortic regurgitation, or a large aortic annulus. However, the data presented suggest that this group offered a Ross procedure to all these categories of patients within a wide age range, 18 to 65 years (mean, 39 years), and outcomes are only represented by survival obtained by matching with the Australian National Death Index.
With accumulation of large series such as this showing low risk and excellent long-term survival, the Ross procedure can no longer be disregarded as an option for younger patients who would like to, should, or must avoid anticoagulation and who have limited size roots in which any prosthesis will provide worse hemodynamics (9). This Journal is a good forum to have this discussion. If the cardiology and cardiac surgery communities accept expanded use of the Ross procedure, let us take to heart the hard lessons learned in the 1990s and leave it in the hands of a limited number of surgeons dedicated to mastering the operation.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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