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Eur J Cardiothorac Surg. 2019 Feb 1;55(2):247-255. doi: 10.1093/ejcts/ezy247.

The Ross procedure versus prosthetic and homograft aortic valve replacement: a systematic review and meta-analysis.

Author information

Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Population Health Research Institute, Hamilton, ON, Canada.
Division of Cardiac Surgery, McMaster University, ON, Hamilton, Canada.
Division of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, Montreal, QC, Canada.
Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada.
Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
Department of Cardiology, "Prof. Dr. CC Iliescu" Institute for Cardiovascular Diseases, Bucharest, Romania.
Division of Cardiology, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland.
Division of Cardiac Surgery, Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada.
Division of Cardiac Surgery, Western University, London, ON, Canada.



Young adults undergoing aortic valve replacement (AVR) have decreased life expectancy compared to matched controls. The Ross procedure aims to improve valve lifespan while avoiding anticoagulation. We prepared a systematic review and meta-analysis to assess the Ross procedure compared to conventional AVR.


We searched MEDLINE, EMBASE and Cochrane CENTRAL for studies evaluating the Ross procedure versus any conventional AVR in adult patients. We performed screening, full-text assessment, risk of bias evaluation and data collection independently and in duplicate. We evaluated the risk of bias with the ROBINS-I and Cochrane tools and quality of evidence with the GRADE framework. We pooled data using the random- and fixed-effects models.


Thirteen observational studies and 2 randomized controlled trials (RCTs) were identified (n = 5346). No observational study was rated as having low risk of bias. The Ross procedure was associated with decreased late mortality in observational and RCT data [mean length of follow-up 2.6 years, relative risk (RR) 0.56, 95% confidence interval (CI) 0.38-0.84, I2 = 58%, very low quality]. The RCT estimate of effect was similar (mean length of follow-up 8.8 years, RR 0.33, 95% CI 0.11-0.96, I2 = 66%, very low quality). No difference was observed in mortality <30 days after surgery. All-site reintervention was similar between groups in cohorts and significantly reduced by the Ross procedure in RCTs (RR 1.41, 95% CI 0.89-2.24, I2 = 55%, very low quality and RR 0.41, 95% CI 0.22-0.78, I2 = 68%, high quality, respectively).


Observational data, with residual confounding, and RCT data suggest a late survival benefit with the Ross procedure with no increased risk of reintervention when compared to conventional AVR. Considering the quality of available evidence and limited follow-up, additional high-quality randomized studies are required to strengthen these findings.

Systematic review PROSPERO registration:



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