Perspective:

The Ross procedure––in which the patient’s native and normal pulmonic valve is substituted for the diseased aortic valve, and a homograft used to replace the pulmonic valve––has been largely abandoned in adult cardiac surgery, except in a few centers and for a few discrete indications. Initial hopes that the procedure would be more durable in young patients have not come to fruition. In addition, the added surgical expertise that is required, as well as the inherent risk involved of iatrogenic conversion of single-valve disease (the aortic valve) to double-valve disease (the aortic and pulmonic valves) have led most surgeons and adult patients to more reproducible procedures. This study appears to make two statements: first, 'long-term' mortality with the Ross procedure is no better than that after mechanical AVR; and second, self-control of anticoagulation is superior and could help yield superior outcomes after mechanical AVR. As to the first point, mean follow-up of 5-6 years in young patients cannot constitute 'long-term' outcomes; and outcomes that are long-term should assess more than all-cause mortality (including freedom from all valve-related morbidity, as well as assessment of quality of life). The use of self-monitored anticoagulation also must account for the population, and the control achieved in a German population might not readily extrapolate to the general population in the United States. Perhaps the best take-home message from this study is that, if a patient elects to undergo mechanical AVR, short-term outcomes in conjunction with tight control of anticoagulation appear to be no worse than short-term outcomes after a more esoteric procedure. Phrased this way, the findings of the study seem less noteworthy.