The Ross Procedure and Patient Perceived Health-Related Quality of Life Outcomes: A 25-year Experience from a Single Institution

M. Salim Hammoud¹, L. Chen², A. Toth³, A. Artis³, J. Rajeswaran³, G. B. Pettersson⁴, E. H. Blackstone⁴, S. Unai⁴, H. Najm⁴, L. G. Svensson⁴, T. Karamlou^5
1Division of Pediatric Cardiac Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, Cleveland, Ohio ²Case Western Reserve University School of Medicine, Cleveland, Ohio ³Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, Cleveland, Ohio ⁴Cleveland Clinic, Cleveland, Ohio ⁵The Cleveland Clinic, Cleveland, Ohio

Purpose: The Ross procedure continues to evolve through a better understanding of technical modifications and patient factors, prompting efforts to contextualize the procedure’s long-term effects. We report our single institution’s experience of long-term clinical and patient-perceived health-related quality of life (HR-QoL) among patients receiving the Ross procedure over time.

Methods: From 1/1990–4/2021, 166 patients underwent an isolated Ross procedure at Cleveland Clinic with a mean age of 35±12 years, and 48 (29%) were females. Median time of follow-up post- procedure was 7 years. Longitudinal hemodynamics were assessed with mixed models. Mortality and reintervention were assessed by parametric hazard models. At cross-sectional assessment, 78 (47%) patients completed the generic PROMIS-10 and cardiac-specific McNew instruments at a median follow-up time of 9.7 years, 22 (13%) were deceased and 66 (40%) were lost to follow-up. The PROMIS-10 instrument included the mental and physical domains, while the McNew consisted of emotional, physical, social domains, in addition to a global score. Random forest regression (RF) was used to assess the relationship between the HR-QoL scores and patient and procedure characteristics. Partial plots were used to depict the relationship between the predicted HR-QoL scores and the variables with the largest predictive influence.

Results: Bicuspid aortic valve (AV) was present in 57 (34%) patients. Mixed etiology which included aortic stenosis and severe AV insufficiency was present in 33(20%) patients before 2000 versus 18 (11%) patients after 2000. In hospital mortality was 1%. Overall survival at 10- and 25-year was 94% and 70%, respectively (Figure1A). A total of 26 reinterventions on AV or aorta were observed for 20 patients; 13/26 included a concomitant pulmonary valve (PV) intervention, with a total of 22 PV interventions done on 18 patients. Freedom from reintervention on AV or aorta at 10- and 25-year was 89% and 72%, respectively. Freedom from intervention on PV at 10- and 25-year was 93% and 72%, respectively. At 20 years, the AV mean gradient was 4.4 mmHg with only 4.6% developing severe AV insufficiency (Figure 1B). For the PROMIS-10 instrument, the mental score was significantly better than normal reference values (P <.001), while the physical score was equivalent (P=.45). McNew scores in all HR-QoL domains were significantly higher than normal reference values (Table 1). Patients who had any reintervention, a higher degree of pre-op AV insufficiency, and a shorter interval since the Ross procedure predicted a lower PROMIS-10 physical HR-QoL score (Figure 1C).

Conclusion: Ongoing favorable long-term hemodynamics, valve durability, and patient-perceived HR-QoL for the Ross procedure, especially in the more recent era, make this an attractive option for young adults with appropriate AV anatomy. Preoperative AV insufficiency is a risk factor for low patient perceived HRQoL. PV interventions remain common, although most can be done in a catheter-based manner. These PV transcatheter procedures may negatively impact the HR-QoL, as patients could perceive the Ross procedure as a “one and done” operation. Our study resonates the importance a comprehensive discussion with the patients to draw inferences on what to expect after the Ross procedure.

Identify the source of the funding for this research project: None