Less Autograft Failure With Secondary Ross Procedure

Quick Takes

  • Secondary Ross procedures after aortic valve repair were associated with superior survival and freedom from autograft reoperation as compared with primary Ross procedures.
  • The study center advocates surgical aortic valve repair as the initial procedure followed by a Ross procedure as necessary.

Study Questions:

What are the outcomes of primary as compared with secondary Ross procedures in infants and children with aortic valve disease?


A retrospective review was performed at a single center. The center favored surgical valve repair for the initial procedure and did not generally perform transcatheter valvuloplasties. All patients who underwent Ross procedures between 1995 and 2018 were included. Propensity score matching for baseline characteristics and risk factors for death and reoperation was performed.


Of 140 Ross procedures performed during the study period, 51.4% (n = 72) were primary operations. Patients undergoing primary Ross procedures tended to be older (median age 8.6 years vs. 7.0 years; p = 0.10) and larger (28.9 kg vs. 19.4 kg; p = 0.07). After propensity score matching resulting in 50 pairs, survival at 10 years was 90.0% in the primary Ross group and 96.8% in the secondary Ross group. Freedom from autograft reoperation at 10 years was 82% in the primary Ross group as compared with 97% in the secondary Ross group (p = 0.03).


The authors concluded that secondary Ross procedure after initial aortic valve surgery achieves superior survival and freedom from autograft reoperation compared with primary Ross procedure.


Aortic valve disease that requires intervention in children continues to present a therapeutic challenge. This study assessed the differences in outcomes in infants and children undergoing primary Ross procedure as compared with those undergoing secondary Ross procedure performed after surgical aortic valve repair. Patients undergoing a secondary Ross procedure generally did better in terms of long-term survival and re-intervention rates. This center is highly experienced both in aortic valve repair and in the Ross procedure. Importantly, the center’s approach has historically been aortic valve repair as the initial “palliative” procedure over transcatheter aortic valvuloplasty. This may limit generalizability of the study to centers with significantly different approaches. The primary limitation of the study is lack of randomization and retrospective design, leaving room for introduction of bias by unidentified variables. Additionally, long-term outcomes for the Ross procedure may be dependent on techniques to stabilize the autograft and present aortic dilatation. In the final years of this study, the authors favored use of a poly-(p-dioxanone) (PDS) band to support the sinotubular junction.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Interventions, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Autografts, Balloon Valvuloplasty, Cardiac Surgical Procedures, Dilatation, Heart Defects, Congenital, Heart Valve Diseases, Infant, Pediatrics, Reoperation, Risk Factors, Treatment Outcome

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