By Jeffrey Zimmet, MD, PhD

Associate Professor of Medicine, University of California, San Francisco; Director, Cardiac Catheterization Laboratory, San Francisco VA Medical Center

SYNOPSIS: Young patients who underwent the Ross procedure recorded high rates of survival and low rates of reintervention long term.

SOURCE: Aboud A, Charitos EI, Fujita B, et al. Long-term outcomes of patients undergoing the Ross procedure. J Am Coll Cardiol 2021;77:1412-1422.

Surgical and interventional options for treatment of aortic valve disease have expanded significantly over the past two decades. In younger patients, options remain more limited. Durability issues with bioprosthetic valves are more pronounced in younger patients. Mechanical valves are featured prominently in the guidelines for this group but come with the need for long-term anticoagulation and anticoagulation-associated morbidity.

The Ross procedure, first performed in 1967,1 uses the patient’s own pulmonic valve as an autograft in the aortic position as a method to closely mimic the hemodynamics of the native aortic root and avoid the early degeneration seen with alternative approaches. Then, the surgeon replaces the pulmonary valve with either a homograft or a xenograft.

Aboud et al reported on long-term follow-up from the European Ross Registry, which includes data about Ross procedures performed at 10 high-volume centers. The registry includes retrospective information collected from 1988 to 2001, combining this with a systematic prospective registry that was initiated in 2002. In all, 2,444 adult patients were included in the Aboud et al analysis. The mean age was 44.1 years, and 75.8% of patients were men. Outcomes were analyzed for the entire group and for the three major subsets of surgical technique: subcoronary, root replacement, or root replacement with additional reinforcement procedures. The integrity of the data was excellent, and follow-up was available for up to 25 years. Mean follow-up was 9.5 years, such that the results presented are most relevant for the period up to 15 years out from surgery.

Overall, these were younger patients with relatively low rates of significant comorbidities. Only 5% of the total were older than age 60 years. Hypertension was the most common coexisting condition (29% of patients). Only 5.1% carried a diagnosis of coronary disease, 2.8% had renal disease, and 2.6% had chronic pulmonary disease. LVEF was > 50% in 87% of patients. A total of 12% of patients underwent a procedure for acute endocarditis, while most had noninfectious aortic stenosis, regurgitation, or combined disease. Early mortality was low (1%). Following the early postoperative period, the authors reported survival of Ross patients was not statistically different from age- and sex-matched controls from the general population. Of the 191 deaths recorded in the study, 86 were cardiac-related and seven were related to redo procedures. Cumulative overall survival was 95.4% at 10 years, 79.4% at 20 years, and 75.8% at 25 years.

A total of 9.2% of patients underwent reinterventions related to the Ross procedure during follow-up. This included a relatively even mix of autograft and right ventricular outflow tract reinterventions, with a minority of reinterventions performed via a transcatheter approach. Freedom from Ross-related reintervention was 95.4% at five years, 84.7% at 15 years, 77.6% at 20 years, and 61.5% at 25 years. Rates of other major adverse events, including bleeding, valve thrombosis, and stroke, were low in the entire cohort. The authors concluded the Ross procedure, when performed by experienced professionals, is associated with good long-term survival and low rates of reintervention and major morbidity. They argued this procedure should be more strongly considered as a treatment option for younger adults with aortic valve disease.


Interventional treatment of aortic valve disease, most particularly in older and higher-risk patients, has advanced significantly over the past decade. This period has seen improvements in minimally invasive surgical techniques, as transcatheter aortic valve replacement (TAVR) has evolved from a niche procedure toward becoming the dominant treatment modality for aortic stenosis. The availability of TAVR, in particular valve-in-valve procedures, has become part of the inevitable creep toward application of these less-invasive procedures as a primary option, even for nonelderly patients.

Some believe a bioprosthesis can be implanted in the aortic position as an initial procedure — even in young patients, either by surgical or transcatheter methods. When this prosthesis succumbs to the inevitable accelerated structural degeneration, it can be treated with downstream valve-in-valve TAVR, or with some mix of TAVR and redo surgery. For patients in intermediate age and risk categories, this may represent a viable strategy. For younger patients, multiple repeat procedures carry their own risks. Current guidelines emphasize a preference for mechanical valves in patients < 50 years of age, and a full discussion of the decision between mechanical and bioprostheses in patients between age 50 and 65 years. The Ross procedure is given a IIb recommendation, with sparse text cautioning the reader about the risk of valve degeneration and both the rate and relative difficulty of reoperation.2

The Aboud et al study was the largest of its kind showing longer-term data from the Ross procedure, demonstrating overall excellent survival and freedom from reintervention. For younger patients with relatively few comorbidities who require aortic valve intervention, the Ross procedure should be a strong consideration when experienced surgeons working in comprehensive valve centers are available.


  1. Sievers HH. Ross procedure. HSR Proc Intensive Care Cardiovasc Anesth 2012;4:119-123.
  2. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021;143:e35-e71.