Quantitative and Functional Evaluation of Both Ventricles Following the Ross Procedure Compared to Conventional Aortic Valve Surgery

Xiaoqin Hua (Hamburg)1, C. Sinning (Hamburg)2, M. Belik (Hamburg)1, S. Yildirim (Hamburg)1, R. Fuhrmann (Hamburg)1, B. Sill (Hamburg)1, E. Girdauskas (Augsburg)3, S. Blankenberg (Hamburg)4, H. Reichenspurner (Hamburg)1, Y. Al Assar (Hamburg)1, J. Petersen (Hamburg)1

1Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 2Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Kardiologie Hamburg, Deutschland; 3Universitätsklinikum Augsburg Herzchirurgie Augsburg, Deutschland; 4Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland



The Ross procedure is a well-established treatment for aortic valve disease (AVD) with excellent long-term outcomes in young and middle-aged patients. Nevertheless, there is limited knowledge on the quantitative and functional alterations of left (LV) and right ventricle (RV) after the Ross procedure.



We included 38 patients aged 18 years or older who underwent a Ross procedure between 2016 and 2023 with high-quality echocardiograms. Using propensity score matching (PSM) for age, sex, NYHA classification, and AVD (regurgitation, stenosis, or combined), we identified 19 pairs with patients who underwent conventional aortic valve replacement or repair (AVR) during the same period. Echocardiographic characteristics, including speckle-tracking echocardiography (STE), were evaluated and compared pre-, postoperatively, and at 3-month follow-up (FU3m).



After PSM, both groups (Ross vs. AVR) had comparable aortic valve pathophysiology, and preoperative NYHA classifications. LV ejection fraction (EF), indexed LV end-systolic volume and end-diastolic volume were not significantly different between groups at any timepoint. Although LV global longitudinal strain (GLS) was similar at baseline and immediately postoperatively, it improved significantly in the Ross group compared to the AVR group at FU3m (-19.0±2.6% vs. -15.9±3.8%, p=0.018). Postoperatively, the mean gradient of aortic valve was lower in the Ross than in the AVR group (5.1±3.1 vs. 9.6±4.9mmHg, p=0.002), and this advantage persisted at FU3m (4.5±2.2 vs. 9.3±2.7mmHg, p<0.001). Quantitative RV parameters were comparable at all time points with the exception of elongated longitudinal dimension in the Ross group at FU3m (77.4±9.6 vs. 70.0±9.4mm, p=0.043). Functionally, the tricuspid annular plane systolic excursion (TAPSE) was significantly reduced in Ross group (12.3±2.4 vs. 15.5±3.1mm, p=0.001), but recovered at FU3m (17.0±3.0 vs. 18.4±4.4mm, p=0.363), while RV fractional area, and free wall longitudinal strain remained comparable at all timepoints.



Compared to conventional aortic valve surgery, there is no evidence of inferior RV function in Ross procedure, except for a transient reduction in TAPSE immediately after surgery. LV function and structure are comparable between the two procedures, while an improvement in GLS was observed three months after the Ross procedure. This improvement is likely to be attributed to the favorable hemodynamics of the autograft, resulting from reduced pressure gradients associated with the native valve.

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