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The Ross Procedure in Adults: A Vanishing Procedure
T. B. Reece1, K. F. Welke2, J. S. Gammie3, S. O'Brien4, F. L. Grover*1. 1University of Colorado, Denver, CO, 2Oregon Health And Science University, Portland, OR, 3University of Maryland, Baltimore, MD, 4Duke Clinical Research Institute, Durham, NC,
BACKGROUND:The Ross procedure remains an option for patients requiring aortic valve replacement. The potential advantages of the Ross Procedure include the avoidance of anticoagulation, the potential for somatic growth, excellent hemodynamics, and potential benefit of autologous tissue in infected fields. Concerns about the procedure include increased operative complexity, homograft durability in the pulmonic position, and potential for creation of double valve pathology. Although the procedure gained popularity in the valve literature over the last two decades, the long term outcomes have tempered the enthusiasm for this procedure in adults. The goal of this study is to describe both the utilization of the Ross Procedure and the perioperative outcomes in the adult population since its inclusion in the Society of Thoracic Surgeons (STS) Adult National Cardiac Database.
METHODS: The STS Adult National Cardiac Database was used to review all Ross procedures performed between 1994 and 2006. The utilization of the procedure in each database was reviewed as were patient demographics, preoperative comorbidities and risk factors. Introperative and perioperative outcomes were assessed.
RESULTS: From 397,074 aortic valve cases reported, 3680 (0.92 percent) were identified as Ross Procedures. Utilization of the procedure peaked in 1998 at 2.1% (574/27729) of all aortic valve procedures then dropped steadily to 0.2% (61/23725) by 2006 (Image 1). Although 334 of the 922 participant sites performed at least one Ross procedure, 80% of the operations occurred only at 84 sites (9.1%) and 8 sites (0.87%) accounted for 25% of the operations. Although patients undergoing Ross Procedures were relatively young (48.5 years) with fewer comorbidities (for example 8% with diabetes and 1% with creatinine >2) than would be expected for most aortic valve patients, the perioperative complications were significant. Intraoperatively, 49% of patients required a blood transfusion. Post-operatively, 6.4% of patients needed reexploration for bleeding or tamponade, 5% experienced renal failure, and 8.7% required prolonged ventilation. Operative mortality was 4.4%.
CONCLUSIONS:There has been a progressive decline in the number of Ross procedures performed for aortic disease in adults during the past decade. Compared to aortic valve replacements with tissue and mechanical valves, the Ross procedure is performed in younger, healthier patients. While the outcomes remain good, these data suggest that the procedure may be riskier for patients than other conventional approaches. Furthermore, the Ross procedure is not commonly performed in the majority of centers reporting in the STS Adults database. Although the Ross procedure may carry inherently higher risk than other aortic valve replacement options, it probably remains a viable option for some patients that might benefit most from the advantages of the procedure at specialized centers performing the procedure more commonly. 
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