Major adverse cardiac events after the Ross operation in 1606 patients: current status of the German-Dutch Ross registry with up to 19 years follow-up

Background: The Ross operation has reached the 5th decade with good long term results from the pioneer series. There is gaining concern however about autograft and allograft durability over time. Furthermore, reports about major adverse cardiac events (MACE) as required by the latest guidelines update, in a large Ross patient cohort are scarce in the literature. It was the aim of this study to report the MACE in patients being treated with the Ross procedure. Methods: 1606 patients (mean age 39.3±16.1, range 0.0 –70.5y), male=1202, female=404) underwent a Ross procedure with a mean follow-up of 5.4±3.9y (7817 pt years, range 0.1–18.7y). Data from the prospective German-Dutch Ross Registry with 12 participating centers were evaluated in accordance to the 2008 guidelines of reporting mortality and morbidity after cardiac valve interventions. Results: Follow-up was complete in 94.6%. All cause mortality was n=69 (4.3%, cardiac=40, 2.5%, unknown=1). Overall survival was 97.7% at 5y and 95.2% at 10y. Structural and non-structural autograft failure with the need of reoperation occurred in n=70 (4.4%), autograft endocarditis with reoperation was present in n=12 (0.8%) resulting in a freedom from autograft reoperation of 97,1% at 5y and 93.0 % at 10y (mean time to reoperation 6.1±4.72y, median 5.7y). Allograft failure with the need of reoperation occurred in n=56 (3.5%) with a freedom from allograft reoperation of 96.9% at 5y and 93.7% at 10y (mean time to reoperation 4,3±3.8y, median 2,6y). 10 valvuloplasties were included in these numbers. Freedom from autograft and allograft reoperation was 94.5% at 5y and 88.1% at 10y. Infective endocarditis (conservative or medically treated) occurred in n=45 (linearized occurrence rate 0.57%/patient-year), thrombotic and thromboembolic events (including transient ischemic attacks) were observed in n=38 (linearized occurrence rate 0.48%/patient-year). Conclusion: A low rate of MACE in the long term after the Ross operation was observed in the registry. The large cohort enables to define subsets of patients who could be at risk for autograft reoperation. Caution ought to be attended to allograft and autograft endocarditis, since almost one fifth of all reoperations were associated with infective endocarditis.