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Age- and sex-matched controls should not be the standard for the Ross procedure

Open AccessPublished:June 01, 2022DOI:https://doi.org/10.1016/j.xjon.2022.05.015
      To the Editor:
      The authors reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
      The optimal treatment for aortic valve pathology in young patients is a subject of debate in the current literature. This subset of patients constitutes a clinical challenge due to their longer life expectancy and increased lifetime risk of prosthesis-related complications.
      • Chen L.
      • Salim Hammoud M.
      • Karamlou T.
      The tale of two valves: role of the Ross procedure for aortic stenosis in young adults.
      With numerous options for aortic valve replacement, the Ross procedure has been championed as the only intervention capable of restoring late survival to that of the age- and sex-matched general population.
      • David T.E.
      • David C.
      • Woo A.
      • Manlhiot C.
      The Ross procedure: outcomes at 20 years.
      • El-Hamamsy I.
      • Toyoda N.
      • Itagaki S.
      • Stelzer P.
      • Varghese R.
      • Williams E.E.
      • et al.
      propensity-matched comparison of the Ross procedure and prosthetic aortic valve replacement in adults.
      Dedicated Ross programs have been established at several high-volume tertiary-care centers, with expert surgeons and ancillary staff experienced in the complex postoperative care required by these patients. Notable disparities in access, quality, and cost of tertiary-care centers have been well-established.
      • Riley W.J.
      Health disparities: gaps in access, quality and affordability of medical care.
      The patient population at these centers is generally highly educated, wealthier, and has longer life expectancies than the general population.
      • Evans L.A.
      • Go R.
      • Warsame R.
      • Nandakumar B.
      • Buadi F.K.
      • Dispenzieri A.
      • et al.
      The impact of socioeconomic risk factors on the survival outcomes of patients with newly diagnosed multiple myeloma: a cross-analysis of a population-based registry and a tertiary care center.
      A recent Society of Thoracic Surgeons Adult Cardiac Surgery Database study of 3054 patients who underwent the Ross procedure across registered centers in North America between 1994 and 2010 reported that 87% of patients were White, compared with 75.1% and 72.4% of the US population from the 2000 and 2010 census, respectively.
      • Reece T.B.
      • Welke K.F.
      • O'Brien S.
      • Grau-Sepulveda M.V.
      • Grover F.L.
      • Gammie J.S.
      Rethinking the Ross procedure in adults.
      ,
      US Census Bureau
      Race and ethnicity in the United States: 2000 census and 2010 census.
      Our own registry of Ross patients between 1990 and 2021 showed similar disparities, with 94% of patients self-reporting as non-Hispanic White compared with 86.1% and 84.5% of the Ohio population from the 2000 and 2010 census, respectively.
      US Census Bureau
      Race and ethnicity in the United States: 2000 census and 2010 census.
      The patient population served by tertiary-care centers does not necessarily reflect the overall population. In context, the average Ross patient, a 43-year-old White male, has a 3.3-year longer life expectancy than his Black counterpart.
      Centers for Disease Control and Prevention
      National Vital Statistics reports (n.d.).
      Appropriate comparisons with age- and sex-matched norms must take into account race in addition to other social determinants of health, such as income, education, marital status, lifestyle factors, and area of residency. This requires more complex analysis than with age- and sex-matched comparisons, so tools from National Institutes of Health data have been constructed to account for such variables.
      • Foster D.
      How Long Will I Live? Life expectancy calculator.
      While the Ross procedure has demonstrated excellent outcomes with superior hemodynamics and freedom from lifelong anticoagulation, the survival benefit must not be overstated and outcomes from high-volume referral centers should not be overgeneralized. Evidence supporting the efficacy of the Ross procedure is promising but remains inconclusive, resulting in a Class IIB recommendation from the 2020 American College of Cardiology/American Heart Association valve guidelines.
      • Writing Committee Members
      • Otto C.M.
      • Nishimura R.A.
      • Bonow R.O.
      • Carabello B.A.
      • Erwin III, J.P.
      • et al.
      2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.
      We caution against describing the Ross procedure as restorative of survival to age- and sex-matched controls without accounting for confounding factors, such as demographics and social determinants of health. We previously reported poorer quality of life in Ross patients relative to matched aortic valve replacement controls, which may reflect greater patient expectations and a potential overstatement of anticipated quality of life in the informed consent process.

      Chen L, Hammoud MS, Ghandour HZ, Artis A, Svensson LG, Johnston DR, et al. Does the Ross operation outperform prosthetic aortic valve replacement in young adults in the long term? Paper presented at: 102nd Annual Meeting of the American Association for Thoracic Surgery; May 14-17, 2022; Boston, Mass.

      Our center's experience in managing the failed autograft after the Ross operation using a variety of strategies, including the Ross reversal procedure, has also demonstrated successful outcomes in a heterogenous cohort of patients who underwent the initial Ross operation at other centers.
      • Hussain S.T.
      • Majdalany D.S.
      • Dunn A.
      • Stewart R.D.
      • Najm H.K.
      • Svensson L.G.
      • et al.
      Early and mid-term results of autograft rescue by Ross reversal: a one-valve disease need not become a two-valve disease.
      • Chen L.
      • Salim Hammoud M.
      • Mahboubi R.
      • Karamlou T.
      Pulmonary conduit reoperation following the Ross procedure.
      • Chen L.
      • Salim Hammoud M.
      • Ghandour H.
      • Frankel W.
      • Karamlou T.
      Risk of endocarditis extension in Ross reintervention with transcatheter pulmonary valve replacement.
      In the context of evaluating all potential aortic valve interventions, we emphasize the importance of holistic review of the evidence in shared decision-making.

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        • Warsame R.
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        The impact of socioeconomic risk factors on the survival outcomes of patients with newly diagnosed multiple myeloma: a cross-analysis of a population-based registry and a tertiary care center.
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        Rethinking the Ross procedure in adults.
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        • Bonow R.O.
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      1. Chen L, Hammoud MS, Ghandour HZ, Artis A, Svensson LG, Johnston DR, et al. Does the Ross operation outperform prosthetic aortic valve replacement in young adults in the long term? Paper presented at: 102nd Annual Meeting of the American Association for Thoracic Surgery; May 14-17, 2022; Boston, Mass.

        • Hussain S.T.
        • Majdalany D.S.
        • Dunn A.
        • Stewart R.D.
        • Najm H.K.
        • Svensson L.G.
        • et al.
        Early and mid-term results of autograft rescue by Ross reversal: a one-valve disease need not become a two-valve disease.
        J Thorac Cardiovasc Surg. 2018; 155: 562-572
        • Chen L.
        • Salim Hammoud M.
        • Mahboubi R.
        • Karamlou T.
        Pulmonary conduit reoperation following the Ross procedure.
        Eur J Cardiothorac Surg. Published online May 6, 2022; https://doi.org/10.1093/ejcts/ezac267
        • Chen L.
        • Salim Hammoud M.
        • Ghandour H.
        • Frankel W.
        • Karamlou T.
        Risk of endocarditis extension in Ross reintervention with transcatheter pulmonary valve replacement.
        J Am Coll Cardiol. 2022; 79: e457https://doi.org/10.1016/j.jacc.2022.01.055