New Long-Term Ross Procedure data

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Teapotimus

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Joined
Dec 19, 2022
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41
Location
USA
Just came across this study excerpt on Ross procedure longevity, appears the entire paper is behind a paywall unfortunately, but the abstract is interesting.

Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure A Post Hoc Analysis of a Randomized Clinical Trial​


https://jamanetwork.com/journals/jamacardiology/article-abstract/2811496
Single center 108 patients, median follow up time of 24.1 years, median age of 38.

71.1% free of reoperation at 25 years.

I was recently talking to some people who are in their third decade of the Ross procedure without reoperation, perhaps the Ross is becoming a viable long term option for young patients. Especially with the newer refinements in technique that aren't encompassed in studies like this.
 
a very encouraging study, however my reservations with The Ross remain to be the following points:

Supply and Demand (aka volume):
Based on this article we can see that "more than 180 000 heart valve replacement surgeries are performed each year in the US"; assuming a hospital doing one valve surgeries per day this works out to about 500 hospitals doing OHS, so lets look at the study's premise:

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

So in 6 years, 8 months, 30 days they managed to do (or managed to find suitable candidates for study inclusion?) 108 patients, so lets call that something like 15 patients per year.

This is literally a drop in the bucket of the needs of the (just the USA) community. Further its absurd to even wonder where the 179, 985 sources of the homografts will be sourced from.

Also to get anywhere near the levels of (probably cherry picked, but I won't do more than mention that) success they have reported clearly high levels of surgical "excellence" are needed. This presents an enormous training problem in and of itself.

This alone should make it clear why The Ross isn't anything more than a Show Pony which is promoted to a highly specific target audience ... :unsure: who would that be? Would it be those who are attempting to avoid anticoagulation therapy? Was it somehow the appeal of your own tissue (ignoring the fact that you'll need someone else's tissue in a valve position which was not diseased, therefore giving you a diseased second valve)


Long term issues:
The very attractive data suggests that at 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%) which I assume breaks down into:
  1. from autograft reintervention, 80.3% {so your valve failed in the Aortic position};
  2. from homograft reintervention, 86.3% {the donor valved in your pulmonary position}.
I say assume, because the text was a little uncertain. Either way in the case of 1. you now have a redo surgery because your own tissue needs to be replaced giving you a redo surgery which is by nature more complex (as is clear in the literature, even if the proponents of The Ross down play that point) and an almost 100% certainty that the othe valve won't really be far behind in the "intervention dice roll".

In the case of 2 you get to keep your own tissue (three cheers) but the homograft needs "reintervention", well and your valve probably isn't far behind.

This is assuming all goes according to this single center's plan. What happens if it doesn't? Well we know anecdotally that a case of endo will see your valve need snipping out and you get something else which may be either a bio-prosthesis (say hello to your third surgery now, and wave at your fourth down the road) or a mechanical and the anticoagulation therapy that you sought to avoid. Of course there's a high likelihood that there's still a third reoperation down the road when the other valve reaches end of life. I'm not making this up as conjecture either, here it is in a recent post where the person lost one valve due to endo
https://www.valvereplacement.org/threads/endocarditis-leading-to-avr-my-story.889366/post-929467
here's a case where the guy lost both valves in 20 years

https://www.valvereplacement.org/th...-soccer-dreams-on-warfarin.888515/post-915690
and another one where aneurysm drove the replacement of the Aortic and he still may face one more surgery (not sure) for the other valve that didn't need to be damaged

https://www.valvereplacement.org/th...cedure-and-life-expectancy.887753/post-900741
So to anyone considering The Ross I would suggest you look through a nice clear lens of analysis (not a foggy rosy one) and go back and ask yourself "why isn't this main stream" still and yet a small band of people are still shilling it up as (to quote the study itself):

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.

my emphasis on 'may be'. As always I would ask the reader to evaluate "if you are feeling lucky"

All in all one has to remember that "do no harm" doe not mean the same as "do what's in the patients best interests".

To put a modern spin on this (and probably get me into trouble) I liken this procedure to the modern trend to harm ones self with cosmetic surgery and surgical implants. Only the practitioners of this will recommend it and other surgeons would perhaps regard it as butchery.

Best Wishes
 
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