Role of the Ross Procedure and Stentless Biological Prostheses in Acute Aortic Valve Endocarditis

Infective endocarditis (IE) is associated with high morbidity and mortality; nearly 40% present with isolated aortic valve (AV) endocarditis. No detailed guidelines on surgical strategies are currently available particularly for younger patients. The aim of this study was to compare mid-term results of conventional valve (aortic valve replacement [AVR]) and root replacement and the Ross procedure in patients <60 years.

Between 1997 and 2023, 176 patients >18 and <60 years underwent surgery for AV IE. Patients with AV repair (n = 44) were excluded; the remaining 132 (male 82%; mean age 46 ± 11 years) underwent a Ross procedure (n = 32), mechanical AVR (n = 28), biological AVR (n = 72). Median and mean follow-up were 6.4 (IQR 2.1-12.9) years and 7.9 ± 6.6 years (1041 patient-years).

Twenty-seven patients (20%; Ross n = 1, biological AVR n = 20, mechanical AVR n = 6; P = .033) required permanent pacemaker implantation, 15 patients had recurrent endocarditis (11%; Ross n = 1, biological AVR n = 11, mechanical AVR n = 3; P = .028). Survival was 78% at 15 years (Ross 92%; biological AVR 72%; mechanical AVR 70%; P = .176). At 15 years, it was 79% after native valve and 73% after prosthetic valve IE (P = .622), and 66% after biological AVR and 93% after root replacement (P = .05). At 15 years, freedom from AV reoperation was 72% (Ross 73%; biological stented AVR 58%; biological stentless root replacement 76%; mechanical AVR 82%; P = .453).

Long-term survival was good after the Ross procedure and stentless biological valves but was best after the Ross procedure with the lowest valve-related complications. Reoperation was non-negligible but similar between the Ross procedure and the stentless biological root. Abscess exclusion with a patch and subsequent valve replacement was associated with inferior results. The Ross procedure offers the best potential for true long-term durability. In patients >50 years, stentless biological root replacement may be an alternative.