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1. JAMA Cardiol. 2018 Aug 25. doi: 10.1001/jamacardio.2018.2946.

[Epub ahead of

Ross Procedure vs Mechanical Aortic Valve Replacement in Adults: A Systematic

Review and Meta-analysis.

Mazine A(1), Rocha RV(1), El-Hamamsy I(2), Ouzounian M(3), Yanagawa B(4), Bhatt
DL(5), Verma S(4), Friedrich JO(6).

Author information:
(1)Division of Cardiac Surgery, Department of Surgery, University of Toronto,
Toronto, Ontario, Canada.
(2)Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec,
(3)Department of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario,
(4)Department of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario,
(5)Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School,
Boston, Massachusetts.
(6)Department of Critical Care Medicine, St Michael's Hospital, Toronto, Ontario,

Importance: The ideal aortic valve substitute in young and middle-aged adults
remains unknown.
Objective: To compare long-term outcomes between the Ross procedure and
mechanical aortic valve replacement in adults.
Data Sources: The Ovid versions of MEDLINE and EMBASE classic (January 1, 1967,
to April 26, 2018; search performed on April 27, 2018) were screened for relevant
studies using the following text word search in the title or abstract: ("Ross" OR
"autograft") AND ("aortic" OR "mechanical").
Study Selection: All randomized clinical trials and observational studies
comparing the Ross procedure to the use of mechanical prostheses in adults
undergoing aortic valve replacement were included. Studies were included if they
reported any of the prespecified primary or secondary outcomes. Studies were
excluded if no clinical outcomes were reported or if data were published only as
an abstract. Citations were screened in duplicate by 2 of the authors, and
disagreements regarding inclusion were reconciled via consensus.
Data Extraction and Synthesis: This meta-analysis was conducted in accordance
with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and
Meta-analysis of Observational Studies in Epidemiology guidelines. Data were
independently abstracted by 3 reviewers and pooled using a random-effects model.
Main Outcomes and Measures: The prespecified primary outcome was all-cause
Results: The search identified 2919 reports, of which 18 studies (3516 patients)
met inclusion criteria, including 1 randomized clinical trial and 17
observational studies, with a median average follow-up of 5.8 (interquartile
range, 3.4-9.2) years. Analysis of the primary outcome showed a 46% lower
all-cause mortality in patients undergoing the Ross procedure compared with
mechanical aortic valve replacement (incidence rate ratio [IRR], 0.54; 95% CI,
0.35-0.82; P = .004; I2 = 28%). The Ross procedure was also associated with lower
rates of stroke (IRR, 0.26; 95% CI, 0.09-0.80; P = .02; I2 = 8%) and major
bleeding (IRR, 0.17; 95% CI, 0.07-0.40; P < .001; I2 = 0%) but higher rates of
reintervention (IRR, 1.76; 95% CI, 1.16-2.65; P = .007; I2 = 0%).
Conclusions and Relevance: Data from primarily observational studies suggest that
the Ross procedure is associated with lower all-cause mortality compared with
mechanical aortic valve replacement. These findings highlight the need for a
large, prospective randomized clinical trial comparing long-term outcomes between
these 2 interventions.

DOI: 10.1001/jamacardio.2018.2946
PMID: 30326489