BACKGROUND: Unicuspid aortic valve (UAV) is the second most common underlying cause of aortic valve dysfunction in young adults after the bicuspid valve. The valve may be replaced (for example by pulmonary autograft) or repaired using the bicuspidization technique. The aim of our study was to compare short- and mid-term outcomes of Ross procedure with bicuspidization in patients with severe UAV dysfunction. METHODS: This was a multi-center retrospective observational cohort study comparing data from two dedicated Ross centers in the Czech Republic with bicuspidization outcomes provided by AVIATOR registry. As for the Ross group, only the patients with UAV were included. Primary endpoint was mid-term freedom from reintervention. Secondary endpoints were mid-term freedom from major adverse events, endocarditis and pacemaker implantation. RESULTS: Throughout the study period, 114 patients underwent the Ross procedure (years 2009-2020) and 126 patients underwent bicuspidization (years 2006-2019). The bicuspidization group was significantly younger and presented with a higher degree of dyspnea, a lower degree of aortic valve stenosis and more often with pure regurgitation. The primary endpoint occurred more frequently in the bicuspidization group than in the Ross group - 77.9 vs. 97.9 % at 5 years and 68.4 vs. 75.2 % at 10 years (p < 0.001). There was no difference in secondary endpoints. CONCLUSION: Ross procedure might offer a significantly lower mid-term risk of reintervention than bicuspidization in patients with UAV. Both procedures have comparable survival and risk of other short- and mid-term complications postoperatively.

Centre of Cardiovascular Surgery and Transplantation Brno Czechia

Cliniques Universitaires Saint Luc Bruxelles Belgium

Department of Cardiac Surgery and Transplantation Brno Faculty of Medicine Masaryk University Brno Czechia

Department of Cardiac Surgery Faculty of Medicine in Hradec Kralove University Hospital Hradec Kralove and Charles University Hradec Kralove Czechia

Department of Cardiovascular Surgery General University Hospital Prague Czechia

East Slovakian Institute for Cardiac and Vascular Diseases Košice Slovakia

Institut Mutualiste Montsouris Paris France

Landeskrankenhaus Salzburg Salzburg Austria

Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai New York NY United States

Saarland University Medical Center Homburg Germany

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Mookadam F, Thota VR, Lopez AM, Emani UR, Tajik AJ. Unicuspid aortic valve in children: a systematic review spanning four decades. J Heart Valve Dis. (2010) 19:678–83. PubMed

Mookadam F, Thota VR, Garcia-Lopez AM, Emani UR, Alharthi MS, Zamorano J, et al. . Unicuspid aortic valve in adults: a systematic review. J Heart Valve Dis. (2010) 19:79–85. PubMed

Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation. (2005) 111:920–5. 10.1161/01.CIR.0000155623.48408.C5 PubMed DOI

Noly PE, Basmadjian L, Bouhout I, Viet Le VH, Poirier N, El-Hamamsy I. New insights into unicuspid aortic valve disease in adults: not just a subtype of bicuspid aortic valves. Can J Cardiol. (2016) 32:110–6. 10.1016/j.cjca.2015.10.028 PubMed DOI

Baumgartner H, De Backer J, Babu-Narayan SV, Budts W, Chessa M, Diller GP, et al. . 2020 Esc guidelines for the management of adult congenital heart disease. Eur Heart J. (2021) 42:563–645. 10.1093/eurheartj/ehaa554 PubMed DOI

Beyersdorf F, Vahanian A, Milojevic M, Praz F, Baldus S, Bauersachs J, et al. . 2021 Esc/Eacts guidelines for the management of valvular heart disease: developed by the task force for the management of valvular heart disease of the european society of cardiology (Esc) and the european association for cardio-thoracic surgery (Eacts). Eur J Cardio-Thorac Surg. (2021) 60:727–800. 10.1016/j.rec.2022.05.006 PubMed DOI

Schäfers HJ, Aicher D, Riodionycheva S, Lindinger A, Rädle-Hurst T, Langer F, et al. . Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg. (2008) 85:2012–8. 10.1016/j.athoracsur.2008.02.081 PubMed DOI

Igarashi T, Matsushima S, Shimizu A, Ehrlich T, Karliova I, Schäfers HJ. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve. Ann Thorac Surg. (2020) 110:111–9. 10.1016/j.athoracsur.2019.10.023 PubMed DOI

de Heer F, Lansac E, El-Hamamsy I, Pibarot P, De Kerchove L, El Khoury G, et al. . The aviator registry: the importance of evaluating long-term patient outcomes. Ann Cardiothorac Surg. (2019) 8:393–5. 10.21037/acs.2019.04.08 PubMed DOI PMC

Matsushima S, Giebels C, Glenske M, Karliova I, Schäfers HJ. Unicuspid valve repair-what technique, which patch for which patient? Ann Cardiothorac Surg. (2019) 8:430–2. 10.21037/acs.2019.05.04 PubMed DOI PMC

Mazine A, Ghoneim A, El-Hamamsy I. The ross procedure: how i teach it. Ann Thorac Surg. (2018) 105:1294–8. 10.1016/j.athoracsur.2018.01.048 PubMed DOI

Matsushima S, Abeln KB, Karliova I, Zacek P, Schäfers HJ. Suture annuloplasty and simplified root wrapping in the full root ross operation. Ann Thorac Surg. (2019) 107:e361–e3. 10.1016/j.athoracsur.2018.11.048 PubMed DOI

Vojacek J, Spatenka J, Holubec T, Zacek P. Coronéo extra-aortic annuloplasty ring could stabilize even the pulmonary autograft annulus in a ross operation. Eur J Cardiothorac Surg. (2013) 43:431–3. 10.1093/ejcts/ezs456 PubMed DOI

Novaro GM, Mishra M, Griffin BP. Incidence and echocardiographic features of congenital unicuspid aortic valve in an adult population. J Heart Valve Dis. (2003) 12:674–8. PubMed

Slostad BD, Witt CM, O'Leary PW, Maleszewski JJ, Scott CG, Dearani JA, et al. . Diagnostic accuracy of echocardiography and intraoperative surgical inspection of the unicuspid aortic valve. Am J Cardiol. (2019) 123:967–71. 10.1016/j.amjcard.2018.12.010 PubMed DOI

Anderson RH. Understanding the structure of the unicuspid and unicommissural aortic valve. J Heart Valve Dis. (2003) 12:670–3. PubMed

Roberts WC, Ko JM. Clinical and morphologic features of the congenitally unicuspid acommissural stenotic and regurgitant aortic valve. Cardiology. (2007) 108:79–81. 10.1159/000095912 PubMed DOI

Matsushima S, Heß A, Lämmerzahl JR, Karliova I, Abdul-Khaliq H, Schäfers HJ. Unicuspid aortic valve repair with bicuspidization in the paediatric population. Eur J Cardiothorac Surg. (2021) 59:253–61. 10.1093/ejcts/ezaa285 PubMed DOI

Kolesar A, Toporcer T, Bajmoczi M, Luczy J, Candik P, Sabol F. Aortic valve repair of a stenotic unicuspid aortic valve in young patients. Ann Thorac Surg. (2018) 105:1351–6. 10.1016/j.athoracsur.2017.12.031 PubMed DOI

Bouhout I, Ghoneim A, Poirier N, Tousch M, Cartier R, Demers P, et al. . Unicuspid aortic valve disease in young adult: should we repair or replace? Can J Cardiol. (2017) 33(10, Suppl):S107. 10.1016/j.cjca.2017.07.211 DOI

Aboud A, Charitos EI, Fujita B, Stierle U, Reil JC, Voth V, et al. . Long-term outcomes of patients undergoing the ross procedure. J Am Coll Cardiol. (2021) 77:1412–22. 10.1016/j.jacc.2021.01.034 PubMed DOI

El-Hamamsy I, Toyoda N, Itagaki S, Stelzer P, Varghese R, Williams EE, et al. . Propensity-matched comparison of the ross procedure and prosthetic aortic valve replacement in adults. J AmCollege Cardiol. (2022) 79:805–15. 10.1016/j.jacc.2021.11.057 PubMed DOI

Etnel JRG, Grashuis P, Huygens SA, Pekbay B, Papageorgiou G, Helbing WA, et al. . The ross procedure: a systematic review, meta-analysis, and microsimulation. Circ Cardiovasc Qual Outcomes. (2018) 11:e004748. 10.1161/CIRCOUTCOMES.118.004748 PubMed DOI

Mazine A, Rocha RV, El-Hamamsy I, Ouzounian M, Yanagawa B, Bhatt DL, et al. . Ross procedure vs mechanical aortic valve replacement in adults: a systematic review and meta-analysis. JAMA Cardiol. (2018) 3:978–87. 10.1001/jamacardio.2018.2946 PubMed DOI PMC

Gofus J, Fila P, Drabkova S, Zacek P, Ondrasek J, Nemec P, et al. . Ross procedure provides survival benefit over mechanical valve in adults: a propensity-matched nationwide analysis. Eur J Cardio-Thorac Surg. (2022) 61:1357–65. 10.1093/ejcts/ezac013 PubMed DOI

Sievers HH, Ensminger S. Update on the German ross registry. Ann Cardiothorac Surg. (2021) 10:515–7. 10.21037/acs-2020-rp-154 PubMed DOI PMC

Abeln KB, Chauvette V, Poirier N, Matsushima S, El-Hamamsy I, Schäfers HJ. Ross operation after failure of aortic valve repair. Ann Cardiothorac Surg. (2021) 10:476–84. 10.21037/acs-2020-rp-19 PubMed DOI PMC

Zakkar M, Bruno VD, Zacek P, Di Centa I, Acar C, Khelil N, et al. . Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach. Eur J Cardiothorac Surg. (2020) 57:308–16. 10.1093/ejcts/ezz193 PubMed DOI