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Excellent Outcome of Ross Procedure After Two Decades


About 83% of adults with aortic valve disease (AVD) who underwent the Ross procedure, which uses a valve substitute that preserves mobility of the neo-aortic root, are still alive at 25 years postprocedure, a survival rate equivalent to that of the general population, results of a new study show. The need for reintervention in these patients is low.


  • The study was a post hoc analysis of a randomized clinical trial that showed superior survival, freedom from reoperation, and quality of life at 10 years for patients who received the Ross procedure compared to those who got homograft root replacement.

  • This new analysis included 108 patients, median age 38 years and mostly male and of British origin, who underwent the Ross procedure. Of these, 45% had aortic regurgitation (AR) as the main hemodynamic lesion.

  • The primary outcome was long-term survival compared with an age-, sex-, and country of origin-matched general UK population using a novel, patient-level matching strategy. Secondary outcomes included freedom from any valve-related reintervention, autograft reintervention, or homograft reintervention.


  • Survival at 25 years was 83.0% (95% CI, 75.5% – 91.2%), representing a relative survival of 99.1% (95% CI, 91.8% – 100%) compared with the matched general population (survival in general population was 83.7%).

  • At 25 years, freedom from any Ross-related reintervention was 71.1% (95% CI, 61.6% – 82.0%); freedom from autograft reintervention was 80.3% (95% CI, 71.9% – 89.6%); and freedom from homograft reintervention was 86.3% (95% CI, 79.0% – 94.3%).

  • There was no increased hazard for autograft deterioration in patients presenting with vs without preoperative AR, an important finding since it has been suggested Ross procedure benefits may not extend fully to patients with preoperative AR, said the authors.

  • 86% of patients had New York Heart Association class I or II status at the latest clinical follow-up (approaching 25 years).


This study shows the Ross procedure “provided excellent survival into the third decade after surgery,” with the new data further supporting “the unique benefits” of the valve substitute in adults, the authors conclude.

Authors of an accompanying editorial, Tsuyoshi Kaneko, MD, Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri, and Maral Ouzounian, MD, PhD, Peter Munk Cardiac Centre, Division of Cardiac Surgery, University Health Network, University of Toronto, write that the new evidence suggests the Ross procedure is “a truly attractive option in younger patients with long life expectancy.” However, they note aortic regurgitation in the cohort worsened over time, potentially leading to late reinterventions, echocardiographic follow-up was available in only 71% of patients, and generalizing the Ross procedure to a broader group of surgeons is challenging.


The study was conducted by Maximiliaan L. Notenboom, BSc, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues. It was published online November 8 in JAMA Cardiology.


The analysis reflects a single-surgeon experience, so it’s difficult to extrapolate the results, although the operative steps involved in the Ross procedure have now been clearly delineated, making the operation reproducible. The duration of echocardiographic follow-up was shorter and less complete than the clinical follow-up. Outcomes of the cohort that underwent homograft procedures in the randomized clinical trial were not reported, but since that procedure has nearly disappeared from practice, reporting on its long-term outcomes would be of limited clinical significance.


Notenboom has disclosed no relevant financial relationships. Co-author Fabio De Robertis, MD, Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, London, England, received nonfinancial support from Edwards Lifescience for travel and personal fees from Bristol Myers Squibb for consulting outside the submitted work, and has a service agreement with Medtronic UK, which paid a fee to the Royal Brompton & Harefield Hospitals Charity Fund.

Editorial co-author Kaneko received personal fees from Edwards Lifesciences, Medtronic, Abbott, and Johnson & Johnson outside the submitted work; Ouzounian received personal fees from Medtronic, Edwards Lifesciences, and Terumo Aortic outside the submitted work.

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  • Posted on November 18, 2023