Ross procedure linked to better outcomes than mechanical AVR: meta-analysis

  • Mazine A & al.
  • JAMA Cardiol
  • 1 Oct 2018

  • curated by Jenny Blair, MD
  • Clinical Essentials
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  • Compared with mechanical aortic valve replacement (AVR), the Ross procedure was associated with better survival and other outcomes but higher reintervention rates in this meta-analysis.
  • Most data derived from observational studies; randomized trials needed.
  • Authors emphasize need for careful patient selection with Ross.

Why this matters

  • Evidence suggests elevated mortality among younger patients undergoing mechanical AVR. 
  • Ross procedure eliminates anticoagulation and attendant risks but is surgically complex and of uncertain benefit vs mechanical AVR.

Key results

  • Median follow-up, 5.8 years.
  • Ross vs mechanical AVR:
    • Mortality: incidence rate ratio (IRR), 0.54 (95% CI, 0.35-0.82; P=.004);
    • Valve- or cardiac-related mortality: IRR, 0.42 (95% CI, 0.18-0.97; P=.04);
    • Heart block requiring pacemaker: risk ratio, 0.40 (95% CI, 0.17-0.94; P=.04);
    • Stroke: IRR, 0.26 (95% CI, 0.09-0.80; P=.02);
    • Major bleeding: IRR, 0.17 (95% CI, 0.07-0.40; P<.001>
    • Mean transaortic valve gradient difference: 9.8 mmHg (P<.001>
    • Reintervention: IRR, 1.76 (95% CI, 1.16-2.65; P=.007);
    • Similar rates of perioperative mortality and morbidity, endocarditis.

Study design

  • Systematic review, meta-analysis, 18 studies (1 randomized clinical trial) comparing Ross procedure vs mechanical AVR (n=3516).
  • Outcome: all-cause mortality.
  • Funding: None disclosed; authors report industry ties.


  • Few randomized data.
  • Follow-up inadequate to explore risks for valve deterioration.
  • Variable Ross techniques, mechanical valve types not assessed.

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