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 under 1 year of age. Methods A systematic review with pooled analyses was conducted according to PRISMA criteria. Inferred individual patient data were extracted from life tables. The primary endpoints were early (≤30 days) and late (>30 days) mortality rates following the Ross procedure in children. Secondary endpoints were freedom from reintervention for the right ventricular outflow tract and pulmonary autograft. These endpoints were assessed in the overall population of children. Sensitivity analyses were performed in subgroups younger than 1 year of age (infants) and in non-infant children. Results A total of 25 studies on 2737 patients met inclusion criteria. The pooled early survival rate was 96.0% [95% CI (95.1 to 96.8%)] overall and 86.8% [95% CI (82.1% to 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 to non-infant children [hazard ratio 3.38, 95% CI (2.44; 4.68), p<0.001]. In meta-regression analyses, younger age was strongly associated with poorer survival and higher reintervention rates. Conclusion 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.