Extending the age cutoff: Outcomes of the Ross procedure in patients older than 60 years. A 2-center retrospective study from the Canadian Ross Registry.

Abstract

The Ross procedure provides excellent long-term survival and hemodynamics in young adults, but its role in older patients remains undefined. Current guidelines and the recent European Association for Cardio-Thoracic Surgery consensus limit recommendations to patients <60 years. We aimed to compare outcomes after the Ross procedure in patients ≥60 versus <60 years. Between 2011 and 2024, 882 consecutive patients underwent the Ross procedure at 2 high-volume centers in Canada. Of these, 134 (15.2%) were ≥60 years (mean 62 ± 2 years) and 748 (84.8%) were <60 years (mean 46 ± 11 years). Outcomes were assessed with overlap-weighted analyses, adjusted for baseline characteristics. Before weighting, older patients had greater rates of hypertension, dyslipidemia, and chronic kidney disease and were more likely to have bicuspid valves, whereas younger patients more frequently presented with aortic regurgitation, unicuspid valve, and previous redo surgeries. After overlap weighting, all variables included in the model achieved excellent balance. Thirty-day mortality was low and comparable (0.9% ≥60 vs 0.5% <60, P = .49). Major perioperative complications were comparable. Median follow-up was 6.1 versus 4.7 years (P = .009). Survival at 9 years was 93.9% in ≥60 versus 97.1% in <60 (log-rank P = .98), both approximating the age- and sex-matched Canadian population. There were no valve-related deaths at follow-up. The 9-year cumulative incidence of all-cause reintervention was low and comparable (7.0% vs 3.9%, P = .42). Hemodynamic performance remained excellent in both groups. The Ross procedure is safe in carefully selected patients ≥60 years, with excellent survival and valve durability up to 10 years, comparable with younger patients. In expert centers, extending the Ross beyond 60 years may represent a valid alternative within lifetime management strategies.