Impact of the Learning Curve on Early Outcomes Following the Ross Procedure

Abstract

Background: Use of the Ross procedure has decreased in recent years, in part because of concerns about operative risks. The aim of this study was to assess the impact of the learning curve on early outcomes when starting a Ross program in the current era.

Methods: From 2011-2016, 200 consecutive Ross procedures were performed in young and middle-aged adults (< 65 years), representing our entire inaugural experience. The cohort was chronologically divided into 2 consecutive periods of 100 patients. Efficiency end points (cross-clamp and bypass times), safety (including mortality and major morbidity) and efficacy end points (aortic or pulmonary regurgitation > 1/4) were compared. A cumulative sum analysis (CUSUM) was performed to evaluate the primary safety end points.

Results: Overall, there were 2 operative mortalities (1%). There was a temporal trend towards reduction in the incidence of major complications after the first period (11 [11%]) vs the second period (4 [4%]; P = 0.06). Similarly, there was a statistically significant improvement in efficiency after the first period regarding cross-clamp times (first period, 194 ± 29 minutes vs second period, 170 ± 28 minutes; P = 0.001) and bypass times (first period, 225 ± 42 minutes vs second period, 205 ± 37 minutes; P = 0.001). CUSUM analysis shows that improvements in safety and efficiency occur after approximately 75-100 cases.

Conclusions: The learning curve associated with the Ross procedure for an early-career surgeon is approximately 75-100 cases, with improvements in safety and efficiency outcomes in a dedicated program. Despite a definite learning curve effect, overall operative mortality remained low.