The Ross Procedure in Children and Infants: A Systematic Review With Pooled Analyses

Background

The Ross procedure is a surgical option for congenital aortic stenosis that involves replacing the diseased aortic valve with a pulmonary autograft. Little is known about outcomes in children, particularly those younger than 1 year.

Methods

A systematic review with pooled analyses was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Inferred individual patient data were extracted from life tables. The primary end points were early (≤30 days) and late (>30 days) mortality rates following the Ross procedure in children. Secondary end points were freedom from reintervention for the right ventricular outflow tract and pulmonary autograft. These end points were assessed in the overall population of children. Sensitivity analyses were performed in subgroups younger than 1 year of age (infants) and in noninfant children.

Results

A total of 25 studies on 2737 patients met inclusion criteria. The pooled early survival rate was 96.0% (95% confidence interval [CI]: 95.1%-96.8%) overall and 86.8% (95% CI: 82.1%-90.3%) among infants. Pooled overall 10-year survival, freedom from pulmonary autograft reintervention, and freedom from right ventricular outflow tract reintervention rates were 91.1%, 90.2%, and 79.7%, respectively. Corresponding pooled rates in infants were 79.3%, 87.1%, and 51.2%. Mortality was significantly higher among infants compared with noninfant children (hazard ratio: 3.38, 95% CI: 2.44-4.68; P < 0.001). In metaregression analyses, younger age was strongly associated with poorer survival and higher reintervention rates.

Conclusions

Modest survival and autograft reoperation rates were observed following the Ross procedure in children. Surgery in infancy was strongly associated with poorer survival and higher reintervention rates.