Long-Term Outcomes of the Ross Procedure

Quick Takes

  • Twenty-five–year survival after the Ross procedure was similar to that of the general population.
  • Overall freedom from reintervention was estimated to be 84.7% at 15 years, 77.6% at 20 years, and 61.5% at 25 years.

Study Questions:

What are the long-term outcomes after the Ross procedure?


A retrospective review was performed using the European Ross Registry for patients undergoing surgery between 1988 and 2018. Endpoints included overall survival, reintervention, and major adverse events. Multivariable regression analyses were performed to identify risk factors for survival and the need for Ross-related interventions.


A total of 2,444 patients with a mean age of 44.1 ± 11.7 years underwent Ross procedures over the course of the study period, with early mortality of 1.0%. Estimated survival 25 years after surgery was 75.8% and was not different from the general population (p = 0.189). Estimated freedom from autograft reintervention was 89.7% at 15 years, 84% at 20 years, and 70.5% at 25 years. The rate of autograft reintervention was 0.69% per patient-year. Estimated freedom from right ventricular outflow tract (RVOT) reintervention was 92.4% at 15 years, 88.9% at 20 years, and 74.3% at 25 years. Estimated freedom from any reintervention was 84.7% at 15 years, 77.6% at 20 years, and 61.5% at 25 years. Larger aortic annulus diameter and preoperative presence of pure aortic insufficiency were independent predictors for autograft intervention. Use of a biological valve in the RVOT (hazard ratio [HR], 8.09) and patient age (HR, 0.97 per year) were independent risk factors for RVOT reintervention.


The authors concluded that the Ross procedure provides excellent survival over a follow-up period of up to 25 years. The rates of reintervention, anticoagulation-related morbidity, and endocarditis were low. The procedure should be considered as a suitable treatment for young patients with aortic valve disease.


The comeback of the Ross procedure continues. Historically, there have been concerns for high reintervention rates, particularly for the autograft due to aortic dilatation. There have a been a number of recent studies demonstrating excellent long-term results with relatively low reintervention rates. Romeo J, et al. (JAMA Cardiol 2021) reported that freedom from autograft intervention was 92% at 15 years, while freedom from homograft reintervention was 97.2%. These rates are somewhat lower but overall comparable to those reported in the current study. Patient selection, technique, and experience are all likely important contributors to the excellent results reported in these recent studies. This study supports the use of the Ross procedure in experienced hands and at dedicated centers as an option for young adults with aortic valve disease.

Clinical Topics: Anticoagulation Management, 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: Allografts, Anticoagulants, Aortic Valve Insufficiency, Autografts, Cardiac Surgical Procedures, Cardiology Interventions, Dilatation, Endocarditis, Heart Defects, Congenital, Heart Valve Diseases, Risk Factors, Transplantation, Autologous, Young Adult

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