Very Long-Term Outcomes After the Ross Procedure

Study Questions:

What is the long-term survival after the Ross procedure, and what factors are associated with Ross-related failure?


A single-center, prospective registry-based study was performed. All patients were prospectively added to a dedicated cardiac surgery registry at the time of the Ross procedure. Complete postoperative clinical examination and history were obtained and transthoracic echocardiograms were performed according to a standardized protocol.


A total of 310 patients with a mean age of 40.8 years (range 18-68 years) were studied. A majority (73.2%) had an underlying diagnosis of bicuspid aortic valve. The most common indication for the Ross procedure was aortic valve stenosis in 72.6% of patients. Freedom from any Ross-related reintervention was 92.9% at 10 years and 70.1% at 20 years. The need for Ross-related reintervention was not associated with decreased long-term survival. Independent risk factors for autograft degeneration was a large aortic annulus preoperatively (hazard ratio [HR], 1.1; p = 0.01), preoperative aortic regurgitation (HR, 2.7; p = 0.02), and concomitant replacement of the ascending aorta (HR, 7.7; p = 0.0003). There were four hospital deaths, all of which occurred relatively early in the experience. As compared with the general population, survival was significantly lower in patients following the Ross procedure as compared with the general population.


The authors concluded that the Ross Procedure was associated with excellent long-term outcomes and survival.


The optimal choice of valve for young patients with aortic valve disease remains controversial. A major advantage of the Ross procedure is the absence of a requirement for systemic anticoagulation. Concerns related to the Ross procedure include the need for re-intervention of the pulmonary homograft, as well as for progressive aortic dilatation or dysfunction of the autograft. The field continues to evolve, particularly in light of advances in transcatheter valve replacements, which may be an excellent choice for patients after the Ross procedure with pulmonary homograft dysfunction. This study shows good long-term results after the Ross procedure. It should be noted that this is a nonrandomized, selected group of patients at an experienced center. As compared with previous studies, this study did demonstrate decreased survival in patients with the Ross procedure as compared with the general population. The authors postulate that this is related to the longer follow-up time in this study.

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

Keywords: Allografts, Aortic Valve Insufficiency, Aortic Valve Stenosis, Autografts, Cardiac Surgical Procedures, Dilatation, Echocardiography, Heart Defects, Congenital, Heart Valve Diseases, Risk Factors, Treatment Outcome

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