The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation

Jonathan R G Etnel; Pepijn Grashuis; Simone A Huygens; Begüm Pekbay; Grigorios Papageorgiou; Willem A Helbing; Jolien W Roos-Hesselink; Ad J J C Bogers; M Mostafa Mokhles; Johanna J M Takkenberg

doi:10.1161/CIRCOUTCOMES.118.004748

The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation

Jonathan R G Etnel
, Pepijn Grashuis
, Simone A Huygens
, Begüm Pekbay
, Grigorios Papageorgiou
, Willem A Helbing
, Jolien W Roos-Hesselink
, Ad J J C Bogers
, M Mostafa Mokhles
, Johanna J M Takkenberg^*

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

BACKGROUND: To support decision-making in aortic valve replacement in children and adults, we provide a comprehensive overview of outcome after the Ross procedure.

METHODS AND RESULTS: A systematic search was conducted for publications reporting clinical outcome after the Ross procedure, published between January 1, 2000, and November 22, 2017. Reported event rates and time-to-event data were pooled and entered into a microsimulation model to calculate life expectancy and lifetime event risk. Ninety-nine publications were included (13 129 patients; total follow-up: 93 408 patient-years, pooled mean follow-up: 7.9±5.3 years). Pooled mean age at surgery was 9.4±5.5 years for children and 41.9±11.4 for adults. For children and adults, respectively, pooled early mortality risk was 4.19% (95% CI, 3.21-5.46) and 2.01% (95% CI, 1.44-2.82), late mortality rate was 0.54%/y (95% CI, 0.42-0.70) and 0.59%/y (95% CI, 0.46-0.76), autograft reintervention 1.28%/y (95% CI, 0.99-1.66) and 0.83%/y (95% CI, 0.68-1.01), and right ventricular outflow tract reintervention 1.97%/y (95% CI, 1.64-2.36) and 0.47%/y (95% CI, 0.37-0.59). Pooled thromboembolism and bleeding rates were low and comparable to the general population. Lifetime risks of autograft and right ventricular outflow tract reintervention were, respectively, 94% and 100% for children and 49% and 19% for a 45-year-old. Estimated life expectancy after surgery was 59 years for children (general population: 64 years) and 30 years for a 45 years old (general population: 31 years).

CONCLUSIONS: Through excellent survival and avoidance of the burden of anticoagulation, the Ross procedure provides a unique opportunity for patients whose preferences do not align with the outcome provided by mechanical valve replacement and for growing children who also benefit from autograft diameter increase along with somatic growth. On the downside, almost all pediatric and many adult Ross patients will require a reintervention in their lifetime.

Original language	English
Pages (from-to)	e004748
Journal	Circulation. Cardiovascular Quality and Outcomes
Volume	11
Issue number	12
DOIs	https://doi.org/10.1161/CIRCOUTCOMES.118.004748
Publication status	Published - Dec 2018
Externally published	Yes

Keywords

Adolescent
Adult
Age Factors
Autografts
Bioprosthesis
Blood Vessel Prosthesis
Blood Vessel Prosthesis Implantation/adverse effects
Child
Child, Preschool
Computer Simulation
Female
Heart Defects, Congenital/diagnosis
Heart Valve Prosthesis
Heart Valve Prosthesis Implantation/adverse effects
Humans
Life Expectancy
Male
Middle Aged
Postoperative Complications/mortality
Risk Assessment
Risk Factors
Time Factors
Treatment Outcome

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10.1161/CIRCOUTCOMES.118.004748

Cite this

Etnel, J. R. G., Grashuis, P., Huygens, S. A., Pekbay, B., Papageorgiou, G., Helbing, W. A., Roos-Hesselink, J. W., Bogers, A. J. J. C., Mokhles, M. M., & Takkenberg, J. J. M. (2018). The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation. Circulation. Cardiovascular Quality and Outcomes, 11(12), e004748. https://doi.org/10.1161/CIRCOUTCOMES.118.004748

@article{d4c6a5ef51904ced94a81d5c67796653,

title = "The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation",

abstract = "BACKGROUND: To support decision-making in aortic valve replacement in children and adults, we provide a comprehensive overview of outcome after the Ross procedure.METHODS AND RESULTS: A systematic search was conducted for publications reporting clinical outcome after the Ross procedure, published between January 1, 2000, and November 22, 2017. Reported event rates and time-to-event data were pooled and entered into a microsimulation model to calculate life expectancy and lifetime event risk. Ninety-nine publications were included (13 129 patients; total follow-up: 93 408 patient-years, pooled mean follow-up: 7.9±5.3 years). Pooled mean age at surgery was 9.4±5.5 years for children and 41.9±11.4 for adults. For children and adults, respectively, pooled early mortality risk was 4.19\% (95\% CI, 3.21-5.46) and 2.01\% (95\% CI, 1.44-2.82), late mortality rate was 0.54\%/y (95\% CI, 0.42-0.70) and 0.59\%/y (95\% CI, 0.46-0.76), autograft reintervention 1.28\%/y (95\% CI, 0.99-1.66) and 0.83\%/y (95\% CI, 0.68-1.01), and right ventricular outflow tract reintervention 1.97\%/y (95\% CI, 1.64-2.36) and 0.47\%/y (95\% CI, 0.37-0.59). Pooled thromboembolism and bleeding rates were low and comparable to the general population. Lifetime risks of autograft and right ventricular outflow tract reintervention were, respectively, 94\% and 100\% for children and 49\% and 19\% for a 45-year-old. Estimated life expectancy after surgery was 59 years for children (general population: 64 years) and 30 years for a 45 years old (general population: 31 years).CONCLUSIONS: Through excellent survival and avoidance of the burden of anticoagulation, the Ross procedure provides a unique opportunity for patients whose preferences do not align with the outcome provided by mechanical valve replacement and for growing children who also benefit from autograft diameter increase along with somatic growth. On the downside, almost all pediatric and many adult Ross patients will require a reintervention in their lifetime.",

keywords = "Adolescent, Adult, Age Factors, Autografts, Bioprosthesis, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation/adverse effects, Child, Child, Preschool, Computer Simulation, Female, Heart Defects, Congenital/diagnosis, Heart Valve Prosthesis, Heart Valve Prosthesis Implantation/adverse effects, Humans, Life Expectancy, Male, Middle Aged, Postoperative Complications/mortality, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome",

author = "Etnel, \{Jonathan R G\} and Pepijn Grashuis and Huygens, \{Simone A\} and Beg{\"u}m Pekbay and Grigorios Papageorgiou and Helbing, \{Willem A\} and Roos-Hesselink, \{Jolien W\} and Bogers, \{Ad J J C\} and Mokhles, \{M Mostafa\} and Takkenberg, \{Johanna J M\}",

year = "2018",

month = dec,

doi = "10.1161/CIRCOUTCOMES.118.004748",

language = "English",

volume = "11",

pages = "e004748",

journal = "Circulation. Cardiovascular Quality and Outcomes",

issn = "1941-7713",

publisher = "Lippincott Williams \& Wilkins",

number = "12",

}

TY - JOUR

T1 - The Ross Procedure

T2 - A Systematic Review, Meta-Analysis, and Microsimulation

AU - Etnel, Jonathan R G

AU - Grashuis, Pepijn

AU - Huygens, Simone A

AU - Pekbay, Begüm

AU - Papageorgiou, Grigorios

AU - Helbing, Willem A

AU - Roos-Hesselink, Jolien W

AU - Bogers, Ad J J C

AU - Mokhles, M Mostafa

AU - Takkenberg, Johanna J M

PY - 2018/12

Y1 - 2018/12

N2 - BACKGROUND: To support decision-making in aortic valve replacement in children and adults, we provide a comprehensive overview of outcome after the Ross procedure.METHODS AND RESULTS: A systematic search was conducted for publications reporting clinical outcome after the Ross procedure, published between January 1, 2000, and November 22, 2017. Reported event rates and time-to-event data were pooled and entered into a microsimulation model to calculate life expectancy and lifetime event risk. Ninety-nine publications were included (13 129 patients; total follow-up: 93 408 patient-years, pooled mean follow-up: 7.9±5.3 years). Pooled mean age at surgery was 9.4±5.5 years for children and 41.9±11.4 for adults. For children and adults, respectively, pooled early mortality risk was 4.19% (95% CI, 3.21-5.46) and 2.01% (95% CI, 1.44-2.82), late mortality rate was 0.54%/y (95% CI, 0.42-0.70) and 0.59%/y (95% CI, 0.46-0.76), autograft reintervention 1.28%/y (95% CI, 0.99-1.66) and 0.83%/y (95% CI, 0.68-1.01), and right ventricular outflow tract reintervention 1.97%/y (95% CI, 1.64-2.36) and 0.47%/y (95% CI, 0.37-0.59). Pooled thromboembolism and bleeding rates were low and comparable to the general population. Lifetime risks of autograft and right ventricular outflow tract reintervention were, respectively, 94% and 100% for children and 49% and 19% for a 45-year-old. Estimated life expectancy after surgery was 59 years for children (general population: 64 years) and 30 years for a 45 years old (general population: 31 years).CONCLUSIONS: Through excellent survival and avoidance of the burden of anticoagulation, the Ross procedure provides a unique opportunity for patients whose preferences do not align with the outcome provided by mechanical valve replacement and for growing children who also benefit from autograft diameter increase along with somatic growth. On the downside, almost all pediatric and many adult Ross patients will require a reintervention in their lifetime.

AB - BACKGROUND: To support decision-making in aortic valve replacement in children and adults, we provide a comprehensive overview of outcome after the Ross procedure.METHODS AND RESULTS: A systematic search was conducted for publications reporting clinical outcome after the Ross procedure, published between January 1, 2000, and November 22, 2017. Reported event rates and time-to-event data were pooled and entered into a microsimulation model to calculate life expectancy and lifetime event risk. Ninety-nine publications were included (13 129 patients; total follow-up: 93 408 patient-years, pooled mean follow-up: 7.9±5.3 years). Pooled mean age at surgery was 9.4±5.5 years for children and 41.9±11.4 for adults. For children and adults, respectively, pooled early mortality risk was 4.19% (95% CI, 3.21-5.46) and 2.01% (95% CI, 1.44-2.82), late mortality rate was 0.54%/y (95% CI, 0.42-0.70) and 0.59%/y (95% CI, 0.46-0.76), autograft reintervention 1.28%/y (95% CI, 0.99-1.66) and 0.83%/y (95% CI, 0.68-1.01), and right ventricular outflow tract reintervention 1.97%/y (95% CI, 1.64-2.36) and 0.47%/y (95% CI, 0.37-0.59). Pooled thromboembolism and bleeding rates were low and comparable to the general population. Lifetime risks of autograft and right ventricular outflow tract reintervention were, respectively, 94% and 100% for children and 49% and 19% for a 45-year-old. Estimated life expectancy after surgery was 59 years for children (general population: 64 years) and 30 years for a 45 years old (general population: 31 years).CONCLUSIONS: Through excellent survival and avoidance of the burden of anticoagulation, the Ross procedure provides a unique opportunity for patients whose preferences do not align with the outcome provided by mechanical valve replacement and for growing children who also benefit from autograft diameter increase along with somatic growth. On the downside, almost all pediatric and many adult Ross patients will require a reintervention in their lifetime.

KW - Adolescent

KW - Adult

KW - Age Factors

KW - Autografts

KW - Bioprosthesis

KW - Blood Vessel Prosthesis

KW - Blood Vessel Prosthesis Implantation/adverse effects

KW - Child

KW - Child, Preschool

KW - Computer Simulation

KW - Female

KW - Heart Defects, Congenital/diagnosis

KW - Heart Valve Prosthesis

KW - Heart Valve Prosthesis Implantation/adverse effects

KW - Humans

KW - Life Expectancy

KW - Male

KW - Middle Aged

KW - Postoperative Complications/mortality

KW - Risk Assessment

KW - Risk Factors

KW - Time Factors

KW - Treatment Outcome

U2 - 10.1161/CIRCOUTCOMES.118.004748

DO - 10.1161/CIRCOUTCOMES.118.004748

M3 - Article

C2 - 30562065

SN - 1941-7713

VL - 11

SP - e004748

JO - Circulation. Cardiovascular Quality and Outcomes

JF - Circulation. Cardiovascular Quality and Outcomes

IS - 12

ER -

The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation

Abstract

Keywords

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