Long-Term Outcomes Following the Ross Procedure

Quick Takes

  • This post hoc analysis of data from a single-center study of 108 adult patients who underwent the Ross procedure for aortic valve disease revealed 25-year survival that was comparable to the general population.
  • There were relatively low rates of reintervention and low 30-day mortality after Ross-related reintervention.

Study Questions:

What are the long-term clinical and echocardiographic outcomes following the Ross procedure in adults with aortic valve disease?


This post hoc analysis was performed on data from a randomized clinical trial comparing homograft root replacement with the Ross procedure among 216 adults <69 years old at a single center from September 1994–May 2001, including patients with ascending aorta dilation, bicuspid aortic valve, active endocarditis, rheumatic valve disease, decreased left ventricular ejection fraction, and prior cardiac surgery. Data after 2010 were collected retrospectively. Reporting only on the Ross procedure subset, the primary endpoint was long-term survival among patients who underwent the Ross procedure compared to a general population matched for age, sex, and country of origin. Secondary endpoints were freedom from any reintervention, autograft reintervention, or homograft reintervention; and time-related valve function, autograft diameter, and functional status.


The study included 108 patients (92 [85%] male, median age 38 years [range 19-66 years]). The Ross procedure was performed in nine patients (8%) with active endocarditis, and 45 (42%) were reoperations; the main hemodynamic lesion was aortic regurgitation (AR) in 49 (45%) and aortic stenosis in 30 (28%). There was one perioperative death (0.9%). Median clinical follow-up was 24.1 years (interquartile range [IQR], 22.6-26.1 years; total 2,488 patient-years; 98% follow-up complete). Median echocardiographic follow-up was 21.7 years (IQR, 6.0-24.3 years; total 1,791 patient-years; 71% follow-up complete). The 25-year survival rate was 83.0% (95% confidence interval [CI], 75.5-91.2%), representing relative survival of 99.1% (95% CI, 91.8-100%) compared to the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6-82.0%), from autograft reintervention was 80.3% (95% CI, 71.9-89.6%), and from homograft reintervention was 86.3% (95% CI, 79.0-94.3%). The 30-day mortality after the first Ross-related reintervention was 0%, and after all Ross-related reinterventions was 3.8% (n = 1). The 10-year survival rate after reoperation was 96.2% (95% CI, 89.0-100%). The probability of developing higher grades of AR increased over time. Autograft root dilation occurred in some but not all patients and was more pronounced in the first 11 years compared to the last 11 years of follow-up.


In this study, the Ross procedure provided excellent survival into the third postoperative decade that was comparable to survival in the general population, and long-term freedom from reintervention albeit with a delayed but progressive functional decline, suggesting that the Ross procedure may be a durable option late into adulthood.


Survival after aortic valve replacement generally is not normal among adults with aortic valve disease. The Ross procedure (autograft aortic valve replacement using the pulmonic valve and placement of a homograft pulmonic valve conduit) is more technically demanding than isolated aortic valve replacement, but it is the only procedure that has been associated with adult survival rates that are comparable to a matched general population. Data from this single-center study previously have shown superior 10-year survival and superior freedom from reintervention for adults who underwent the Ross procedure compared to homograft aortic root replacement (El-Hamamsy I, et al., Lancet 2010;376:524-31). This study, reporting only on patients in that trial who underwent the Ross procedure, extends the duration of clinical follow-up, and demonstrates 25-year survival comparable to a matched general population, reasonable rates of freedom from reintervention, and low mortality after reintervention. The data are supportive of the selective use of the Ross procedure. However, because of the technical demands of the procedure, it would not be appropriate to extrapolate data from this single-center study to general cardiac surgical practice; as the authors note, the Ross procedure ideally should be performed at a Ross center of excellence.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Cardiac Surgical Procedures, Heart Valve Diseases

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