State-of-the-art: Insights from the Ross Registry

Abstract

The treatment of aortic valve disease in young patients is still a major clinical challenge, as the pre-eminent emphasis is on durability and long-term outcomes beyond 10 to 15 years, sometimes >20 to 30 years. The Ross procedure uses the autologous pulmonary valve as an aortic valve substitute and aims to improve valve durability while avoiding anticoagulation and therefore achieve a sustained long-term result with regard to survival, valve functionality, and quality of life. However, this procedure is technically demanding and only performed at a low frequency. Data investigating the Ross procedure are mostly limited to observational studies from single expert centers, while sufficient randomized data are almost completely lacking. Therefore, to create a clinically relevant database of this therapy, the multicenter Ross Registry was founded in 2001. New patients were included, follow-up of past patients continuously updated, and outcomes regularly reported. Throughout recent years, numerous analyses have been performed to characterize this patient population, surgical techniques, risk factors for morbidity and mortality, and most importantly survival outcomes. Currently, more than 2500 patients are included, and the long-term follow-up has reached >25 years in the very first patients who were included. In the most recent study, 2444 adult patients with a mean age of 44.1 ± 11.7 years were analyzed, and it showed that excellent mid-term survival is maintained after 25 years. In addition, the rate of reintervention was lower than reported in patients with xenografts and anticoagulation-related morbidity lower than reported in patients with mechanical valves. In the absence of robust randomized controlled trials, registry data are very important to monitor outcomes and mirror the quality of current practice. Therefore, the Ross Registry provides a unique and important data base regarding treatment of aortic valve disease in young patients.

Keywords: Ross procedure; SAVR; aortic regurgitation; aortic stenosis; pulmonary autograft; young patients.

Schematic depiction of the Ross procedure and its surgical techniques.

Figure 1

Schematic depiction of the Ross procedure and its surgical techniques. A, Subcoronary technique. B, Root-replacement technique. C, Root replacement + reinforcement technique. D, View of the aortic and pulmonic valve, both replaced by semilunar valves.

Figure 2

Characteristics of the Ross Registry. A, Cases per contributing center. B, Age and sex distribution of currently enrolled patients.