Long-term data highlight Ross procedure's safety, effectiveness in younger patients
Long-term outcomes data for patients undergoing the Ross procedure confirm that it is an effective treatment option for younger patients, according to Ismail lsmail El-Hamamsy, MD, PhD, director of aortic surgery for the Mount Sinai Health System. He spoke with Cardiovascular Business about new data showing the procedure might be a better option for some heart patients than mechanical valves or transcatheter aortic valve replacement (TAVR).
The advanced surgical technique for aortic valve disease replaces the diseased valve with the patient’s own pulmonary valve, and then a donor valve is used to fill the pulmonary position. El-Hamamsy said the living valve works much better as a long-term replacement than a mechanic, bioprosthetic or cadaver valve.
"The Ross procedure replaces the patient's diseased aortic valve, but instead of using a biological valve or a mechanical valve, what we do is we borrow another valve in the heart, the pulmonary valve. I want something that is living. I want something that is the patient's own, autologous, and that looks exactly like a normal aortic valve that has three leaflets that open and shut."
The new long-term data presented by El-Hamamsy at the American Heart Association (AHA) meeting in 2024 included 455 patients treated over 15 years at Mount Sinai, which now performs the largest number of Ross procedures worldwide. After 12 years of follow-up, the cumulative incidence of any reintervention was only 4%, and survival matched that of the general population. He said that is a milestone rarely achieved with artificial valves.
"These are actually quite remarkable results that we're very happy about for our patients because it really allows them to hope for a completely normal life expectancy and a normal quality of life, even though they need these surgical procedures done at a younger age than anybody would wish for in terms of open heart surgery," El-Hamamsy explained.
The data show significant improvement in the durability of the Ross procedure compared to what was published previously in the literature. He said that is based on a combination of two things. One is the tailored surgical approach to the patient's anatomy and to the anatomy of the valve, and the second is the postoperative management of the patients, including blood pressure control for the first year.
A natural solution for younger patients
The Ross procedure is typically reserved for younger patients under 60 or 65, particularly those with a long life expectancy whose valves cannot be repaired.
"You really want to have your best player sit in that position, and putting the patient's own pulmonary valve there is the ideal solution, better than any artificial replacement," El-Hamamsy said. "Putting something that is not the patient's own in the pulmonary position where the pressures are lower, where the stresses are lower, where the right-sided chambers work a lot less hard, is perfectly suitable because they last longer. But, if you put something that is not the patient's own in aortic position at age 30, 40 or 50, it's really not going to last a very long time."
By contrast, traditional bioprosthetic valves made from cow or pig tissue, and mechanical valves made from synthetic materials, come with tradeoffs. This includes a limited lifespan, increased risk of infection or stroke, and in the case of mechanical valves, the need for lifelong anticoagulation therapy. But with the Ross procedure, he is seeing restored survival in the longterm without those limitations.
Ross procedure can be complementary to TAVR
The rapid rise of TAVR has transformed the treatment of aortic stenosis, particularly among older patients. However, El-Hamamsy emphasized that the Ross procedure and TAVR are complementary, not competing, techniques.
"TAVR a great technology for older patients and it has now proven quite effective and safe in patients who are low risk. But the main thing to avoid confusion over is low risk and low age. Low-age patients are almost always low risk, but most importantly, they have a long runway ahead of them. And if you have many years of anticipated life expectancy, you really have to be thinking long term."
Despite the growth of TAVR, El-Hamamsy said the number of Ross procedures in the U.S. has increased nearly tenfold over the past decade as new data have validated its durability and survival advantages. He said the number of patients with aortic valve disease seeking treatment with minimally invasive TAVR has at least gotten them in the door to have a conversation with a surgeon. Often in younger patients, they are presented the facts on why surgery is a better option for them, which has helped increase surgical volumes.
Rising Ross volumes and the importance of expertise
Mount Sinai’s surgical volumes reflect the renewed interest in this procedure.
"We'll be doing almost 125 Ross procedures at Mount Sinai, whereas compare to 10 years ago we were only doing about 30 Ross procedures. So everything has really increased and that is a result of being able to offer all of these options to patients from these repair and reconstructive surgical techniques to very complex TAVR procedures. We can really offer tailored solutions to patients from very young to very old in a very safe, but importantly in a very effective way in terms of their long-term benefits," El-Hamamsy said.
Still, he cautioned that the Ross procedure remains technically demanding and should be concentrated in high-volume centers with specific expertise.
“The relationship between surgical volume and outcomes has always been clear in cardiac surgery,” he said. “For complex operations like the Ross, regionalizing care to experienced centers ensures safety and long-term success.”
He said the long-term data presented at AHA underscore that point. With refined surgical techniques, meticulous patient selection, and close postoperative management, particularly in blood pressure control over the first year, El-Hamamsy’s team has achieved survival and durability results that rival native heart function.
"It really allows patients to hope for a completely normal life expectancy and a normal quality of life," he said.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]