56. The Ross Resurgence: North American Trends in Utilization and In-Hospital Outcomes

OBJECTIVE: To evaluate contemporary trends in utilization of the Ross procedure in adults and investigate the relationship between surgical volumes and in-hospital mortality.

METHODS: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for patients who underwent the Ross procedure between 2008 and 2022. We used mixed-effects logistic regression, incorporating center- or surgeon-specific random intercepts, to investigate the relationship between Ross volumes and in-hospital mortality. Statistical significance was evaluated using likelihood ratio tests. We also used propensity score matching and conditional logistic regression to compare in-hospital mortality between the Ross procedure and conventional AVR.

RESULTS: A total of 1,855 patients undergoing the Ross procedure were identified. Median age was 43 years (IQR: 32–53), and 1,237 (67%) patients were male. Utilization of the Ross procedure reached a nadir in 2017 (n=64) before increasing annually, reaching 344 cases in 2022 (Figure 1A). In 2017, Ross procedures represented 0.5% of all AVRs performed on patients aged ≤60 years; by 2022, this proportion had increased to 3.1%. There was a steady decline in the rates of in-hospital mortality associated with the Ross procedure, from a peak of 3.7% in 2008 to a nadir of 0.7% in 2022 (Figure 1B). Compared with centers that performed 1–2 Ross procedures annually, in-hospital mortality was lower in centers that performed 3–10 (OR 0.56 [95% CI: 0.24–0.89]) and ≥11 (OR 0.18 [0.06–0.52]) Ross operations per year (p=0.013). Similarly, compared with surgeons who performed 1–2 Ross procedures per year, in-hospital mortality was lower for surgeons who performed 3–10 (OR 0.37 [0.17–0.78]) and ≥11 (OR 0.23 [0.07–0.70]) Ross operations per year (p=0.007). Propensity-matched analysis demonstrated similar in-hospital mortality between the Ross procedure and conventional AVR (OR 1.12 [0.55–2.28]; p=0.76).

CONCLUSIONS: Utilization of the Ross procedure is increasing in North America, while the mortality associated with this operation has been steadily decreasing. An inverse relationship exists between annual surgical volumes and in-hospital mortality associated with the Ross procedure. In contemporary practice, the in-hospital mortality associated with the Ross procedure is comparable to that of conventional AVR. These findings provide important insights for the lifetime management of young adults with aortic valve disease.

Amine Mazine (1), Chun-Po Steve Fan (2), Joanna Chikwe (3), Nimesh Desai (4), Jennifer C.-Y. Chung (2), Jad Malas (3), Qiudong (Kevin) Chen (3), Michael Bowdish (3), Joseph Bavaria (4), Maral Ouzounian (2), (1) University of Toronto, Toronto, ON, (2) Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, (3) Cedars-Sinai Medical Center, Los Angeles, CA, (4) Hospital of the University of Pennsylvania, Philadelphia, PA

Stephan Ensminger

Commentator

Stephan Ensminger, MD, DPhil is a Professor of Cardiothoracic Surgery and Head of the Department of Cardiac and Thoracic Vascular Surgery at the University of Lübeck, Germany. Dr. Ensminger graduated from the University of Würzburg Medical School in 1996 and received a D.Phil. in Transplantation Immunology from the University of Oxford, U.K. in 2000. He obtained his cardiothoracic surgery training at the Universities of Tuebingen, Erlangen-Nürnberg and the Heart and Diabetes Center NRW at Bad Oeynhausen, Germany. His basic science interests are Transplantation Immunology with the main focus on the immunobiology of cardiac allograft vasculopathy (CAV) and experimental and clinical applications of stem cell engineered heart repar. Clinical interest include minimally invasive AV-valve repair, aortic valve repair and ROSS, OPCAB/MIDCAB and catheter based valve therapies.

Amine Mazine

Abstract Presenter

Amine received his Medical Degree and a Master’s of Science from the University of Montreal. After medical school, he joined the Cardiac Surgery Residency program at the University of Toronto, where his clinical interest crystallized around congenital heart disease and complex valve surgery. In 2023, Amine received his PhD in Biomedical Engineering at the University of Toronto. The topic of his thesis was the generation of the cardiac valve lineage from human pluripotent stem cells. Amine also has a keen interest in the global burden of heart disease in the developing world and takes part in yearly surgical missions to countries such as Egypt and Ethiopia.