Differential approach to choosing between the Ross procedure and aortic homograft implantation in aortic root surgery

Introduction. Aortic root pathology requiring surgical correction with aortic valve replacement remains one of the most challenging problems in modern cardiac surgery, particularly in young and middle-aged patients. The Ross procedure and aortic homograft implantation are recognized biological methods of aortic root reconstruction, each with specific advantages and limitations. At the same time, the choice of the optimal surgical strategy in many cases is largely based on the individual experience of the surgeon, while objective, formalized decision-making criteria remain insufficiently defined.

Aim: To evaluate the factors influencing the choice between the Ross procedure and aortic homograft implantation in aortic root surgery and to develop a surgical decision-making algorithm based on regression analysis.

Material and Methods. A single-center retrospective comparative study included 43 patients with aortic root pathology who underwent full-root aortic replacement between 2015 and 2025. An aortic homograft was implanted in 19 patients (Group I), and the Ross procedure was performed in 24 patients (Group II). Men accounted for 86.0% (n = 37). The mean age was 49.8 ± 13.6 years, body mass index (BMI) was 26.4 ± 4.0 kg/m², and body surface area (BSA) was 1.95 ± 0.17 m². The mean follow-up duration was 58.2 ± 13.9 months in Group I and 74.9 ± 11.3 months in Group II. All patients underwent serial echocardiography preoperatively, in the early postoperative period, and during follow-up. Primary endpoints were overall survival and freedom from reoperation. Secondary endpoints included structural graft degeneration, aortic root/autograft dilatation, aortic regurgitation ≥ grade II, and thromboembolic and hemorrhagic complications. Statistical analysis was performed using IBM SPSS STATISTICS 26.0.

Results. The groups did not differ significantly in age (51.3 ± 15.2 vs 48.6 ± 12.3 years; p > 0.05), BMI (25.8 ± 4.2 vs 26.7 ± 3.8 kg/m²), or BSA (1.94 ± 0.18 vs 1.96 ± 0.16 m²). In the aortic homograft group, infective endocarditis (36.9% vs 4.2%; p = 0.007), previous cardiac surgery (36.8% vs 8.3%; p = 0.024), and connective tissue dysplasia (26.3% vs 4.2%; p = 0.040) were more frequent. In-hospital mortality was 4.7% (n = 2) and occurred only in Group I; no deaths were recorded in Group II. Overall mid-term survival was 90.9%. No reoperations were required in Group I; in Group II, two reoperations (8.3%) were performed at 80 and 96 months. During follow-up, the maximum transaortic flow velocity increased from 118 ± 10 to 126 ± 11 cm/s in Group I (p = 0,006) and from 141 ± 18 to 146 ± 19 cm/s in Group II (p = 0.242). No significant aortic regurgitation ≥ grade II was observed. Age was identified as an independent predictor of graft dysfunction progression: for aortic homografts, AUC = 0.795 with a threshold of 61.5 years (sensitivity 62.5%, specificity 90.9%; p = 0.032); for the Ross procedure, AUC = 0.976 with a threshold of 49,5 years (sensitivity 100%, specificity 85.7%; p = 0.001). Additional risk factors included increased left ventricular myocardial mass (270 ± 90 vs 211 ± 48 g; p = 0.044) and myocardial ischemic time ≥ 130 minutes (AUC = 0.864; p = 0.008).

Conclusion. Age is a key independent predictor of graft dysfunction. In patients with aortic homografts, an increased risk of dysfunction progression is associated with younger age (< 61.5 years), whereas after the Ross procedure an unfavorable prognosis is observed in patients older than 49.5 years. These findings highlight the fundamental importance of age-oriented selection of the aortic root reconstruction method to optimize mid-term outcomes.

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