IS THE ROSS PROCEDURE A REPRODUCIBLE OPERATION? A MULTICENTER PERSPECTIVE

BACKGROUND The Ross procedure offers several advantages in patients requiring aortic valve replacement (AVR). However, it is a more complex procedure than a standard AVR. Whether there is a risk associated with expanding its eligibility and having multiple surgeons performing this operation remains a matter of debate. METHODS AND RESULTS From 2011-2020, 568 Ross procedures were performed by 5 surgeons in 2 Canadian institutions. The cohort was divided in 5 periods of 100 patients (P1 through P5) per center to assess efficacy and safety throughout time. The efficacy endpoints were cross-clamp time, bypass time and aortic regurgitation (AR)>1 at discharge. Safety was assessed with a cumulative sum analysis (CUSUM) adjusted using the STS score. The mean age increased throughout the study period (P1: 45±13 years, P2: 47±12 years, P3: 47±12 years, P4: 48±11 years, P5: 53±10 years; p 1 (1 in P2 and 1 in P5; p=0.76). The CUSUM analysis showed that the risk of complications decreased after 100 cases (Figure 1). Three patients had a perioperative myocardial infarction (1 in P4 and 2 in P5; p=0.25) and 3 patients presented a transient ischemic attack (2 in P1 and 1 in P2; p=0.70). There was a non-statistically significant decrease in the need for temporary dialysis (P1: 5 patients, P2: 3 patients, P3: 0 patient, P4: 1 patient, P5: 1 patient; p=0.08). A similar trend was observed in terms of reintervention for bleeding (P1: 5 patients, P2: 1 patient, P3: 0 patient, P4: 2 patients, P5: 0 patient; p=0.10). The perioperative outcomes did not differ between centers. Two patients died within 30-days, both during P1 (p=0.20). There was no perioperative death in center 2. The overall mortality was 0.4%, (O/E ratio=0.24). CONCLUSION In dedicated programs, the learning curve for the Ross procedure is ≈70 cases. Following this initial phase, nor the addition of other experienced surgeon or increased patient comorbidities had a significant impact on safety and efficacy. Overall mortality remained lower than predicted.