Reevaluating the Ross Procedure in Adults: Insights from a Large Contemporary Cohort

Highlight

• The Ross procedure in adults shows outstanding 12-year survival comparable to the general population.
• Long-term valve performance is excellent, with low incidences of autograft and pulmonary homograft reinterventions.
• Patients with preoperative aortic regurgitation and those older than 50 years achieve favorable outcomes, expanding the procedure’s indications.
• Operative mortality and complication rates are very low in this contemporary, high-volume cohort.

Study Background

Aortic valve disease, including aortic stenosis and regurgitation, poses a significant clinical challenge, especially in younger adults where prosthetic valve replacement options carry limitations such as lifelong anticoagulation or structural valve deterioration. The Ross procedure, involving autograft replacement of the diseased aortic valve with the patient’s pulmonary valve and replacement of the pulmonary valve with a homograft, offers the potential advantages of physiologic valve function and avoidance of anticoagulation. Despite its promise, broad adoption in adults has been limited historically due to concerns about technical complexity, autograft durability, and late reinterventions. With advances in surgical technique and imaging, there has been renewed interest in this procedure. However, robust long-term data utilizing contemporary techniques to guide current clinical practice have been lacking.

Study Design

This study prospectively evaluated 455 consecutive adults undergoing the Ross procedure at a single, high-volume tertiary center between 2011 and 2019, including the center’s initial experience performing the procedure. The mean patient age was 47 ± 12 years with predominance of male patients (73%). All patients underwent systematic longitudinal follow-up comprising clinical evaluation and echocardiography, with a median follow-up duration of 9.0 years and exceptional follow-up completeness for both clinical and imaging data (98%). Outcomes assessed included operative safety, overall survival, valve hemodynamics including gradients, autograft root dimensions, and rates of reintervention on the autograft or pulmonary homograft valves. The study aimed to benchmark the long-term efficacy and safety of the Ross procedure using current surgical methodologies in a real-world adult population.

Key Findings

The Ross procedure demonstrated an exceptionally low operative mortality rate of 0.4% (2 patients) with minimal early morbidity, including a 0.8% rate of permanent pacemaker implantation. Importantly, no patient-prosthesis mismatch was observed, indicating excellent valve size matching and function.

Long-term survival at 12 years after surgery matched that of the age- and sex-matched general population, signifying that the Ross procedure restores life expectancy effectively in this cohort. Autograft valve durability was strikingly favorable, with a cumulative incidence of reintervention only 1.1% ± 0.5% at 12 years, and this did not differ significantly between patients presenting with preoperative aortic regurgitation versus aortic stenosis. Pulmonary homograft reintervention was similarly low at 1.9% ± 0.9%. The cumulative rate of any cardiac-related reoperation remained low at 3.5% ± 1.0% over the same follow-up period.

Echocardiographic data supported these clinical findings, revealing durable valve hemodynamics with a mean aortic valve gradient of just 4.0 ± 0.2 mm Hg at 12 years. This stable gradient suggests preserved autograft valve function without stenosis, an important marker that prosthetic valves commonly fail to maintain long-term.

Notably, the data also support the use of the Ross procedure in adults older than 50 years and those with preoperative aortic regurgitation, populations sometimes considered higher risk or less ideal for this surgery.

Expert Commentary

This comprehensive prospective evaluation provides one of the most compelling contemporary datasets affirming the efficacy and safety of the Ross procedure in adult patients. The near-normal survival rates and minimal reintervention underscore the procedure’s ability to not only correct valve pathology but also restore a near-physiologic state that benefits long-term clinical outcomes.

The findings address historical concerns about autograft failure and reinforce that, when performed in experienced centers utilizing contemporary surgical techniques, the Ross procedure offers a compelling alternative to mechanical or bioprosthetic valves. This has considerable implications for patient quality of life by eliminating anticoagulation requirements and providing excellent valve hemodynamics.

However, the study’s single-center design may limit external generalizability, highlighting the need for dissemination of expertise and techniques to broader surgical communities. Additionally, further studies investigating the Ross procedure in varied patient populations and multi-institutional settings will be crucial before universal recommendations can be made.

In the context of guidelines, this evidence supports reconsidering the Ross procedure’s indications, advocating inclusion of suitable older adults and those with aortic regurgitation, who have traditionally faced limited options.

Conclusion

This large, meticulously followed contemporary cohort demonstrates that the Ross procedure in adults is associated with excellent long-term survival akin to the general population, durable valve function, and low incidences of required reintervention. These findings validate the procedure as a superior valve replacement strategy for carefully selected adults, including older patients and those with aortic regurgitation, when performed in centers with substantial expertise.

Clinicians should consider broader incorporation of the Ross procedure into treatment algorithms for adult aortic valve disease, balancing patient-specific factors and surgical expertise. Future research should aim at refining patient selection, expanding training in this complex operation, and further longitudinal assessments to solidify its role in contemporary valvular heart disease management.

Funding and ClinicalTrials.gov

The original study was conducted at a high-volume tertiary center with no stated external funding. Clinical trial registration details were not specified.

References

• El-Hamamsy I, Chauvette V, Bouhout I, Louro K, Poirier N, Demers P. Contemporary Outcomes of the Ross Procedure in Adults: Implications for Current Clinical Practice. J Am Coll Cardiol. 2026 Jun 23;87(24):3400-3410. PMID: 42339796.
• David TE. The Ross procedure: how I do it. Ann Cardiothorac Surg. 2013 May;2(3):336-43. doi: 10.3978/j.issn.2225-319X.2013.07.20.
• Ismail SR, Stratford P, Missouris CG. The Ross operation: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2014 Mar;45(3):387-95.