Clinical and cost-effectiveness of the Ross procedure versus conventional aortic valve replacement in young adults

Objectives In young and middle-aged adults, there are three current options for aortic valve replacement (AVR), namely mechanical AVR (mechAVR), tissue AVR (biological AVR) and the Ross operation, with no clear guidance on the best option. We aim to compare the clinical effectiveness and cost-effectiveness of the Ross procedure with conventional AVR in young and middle-aged adults. Methods This is a systematic literature review and metaanalysis of AVR options. Markov multistate model was adopted to compare cost-effectiveness. Lifetime costs, quality-adjusted life years (QALYs), net monetary benefit (NMB), population expected value of perfect information (EVPI) and expected value of partial perfect information were estimated. Results We identified 48 cohorts with a total number of 12 975 patients (mean age 44.5 years, mean follow-up 7.1 years). Mortality, bleeding and thromboembolic events over the follow-up period were lowest after the Ross operation, compared with mechAVR and biological AVR (p< 0.001). Aortic reoperation rates were lower after Ross compared with biological AVR, but slightly higher when compared with mechAVR (p< 0.001). At a willingnessto- pay threshold of pound 20effective. At a willingness-to-pay threshold of pound 20, 000 per QALY000 per QALY, the Ross procedure is more cost-effective compared the Ross procedure is more cost-effective compared withwith conventional AVR, with a lifetime incremental NMB of pound 60 conventional AVR, with a lifetime incremental NMB of pound 60 952 (952 ( pound pound 3030 236236 to to pound pound 7979 464). Incremental costs were pound 12464). Incremental costs were pound 12 323 (323 ( pound pound 61086108 to to pound pound 1515 972) and incremental QALYs 3.66 (1.81972) and incremental QALYs 3.66 (1.81 to to 4.76). The population EVPI indicates that a trial costing up to pound 2.03 million could be cost 4.76). The population EVPI indicates that a trial costing up to pound 2.03 million could be cost--effective. At a willingness-to-pay threshold of pound 20 000 per QALY, the Ross procedure is more cost-effective compared with conventional AVR, with a lifetime incremental NMB of pound 60 952 ( pound 30 236 to pound 79 464). Incremental costs were pound 12 323 ( pound 6108 to pound 15 972) and incremental QALYs 3.66 (1.81 to 4.76). The population EVPI indicates that a trial costing up to pound 2.03 million could be cost-effective. Conclusions In young and middle-aged adults with aortic valve disease, the Ross procedure may confer greater quality of life and be more cost-effective than conventional AVR. A high-quality randomised trial could be warranted and costeffective.