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Ross procedure

The Ross procedure is a specialized cardiac surgical technique used to treat severe aortic valve disease, in which the patient's diseased aortic valve is excised and replaced with their own pulmonary valve (known as a pulmonary autograft), while the resulting defect in the pulmonary position is repaired using a donor pulmonary valve homograft.^[1]^[2]^[3] Developed in 1967 by British surgeon Donald Ross, the procedure employs a total root replacement method to implant the autograft, preserving the sinuses of Valsalva for optimal hemodynamics and long-term durability.^[3]^[4]^[5] Primarily indicated for patients under 60 years of age with aortic stenosis, regurgitation, or endocarditis-related damage, and a life expectancy exceeding 15 years, the Ross procedure is particularly advantageous for children and young adults due to the autograft's capacity to grow with the patient.^[2]^[3]^[6] It is contraindicated in individuals with connective tissue disorders, such as Marfan syndrome, or chronic end-organ dysfunction.^[3]^[4] The surgery requires open-heart techniques under cardiopulmonary bypass, typically lasting 4-6 hours, and is performed by experienced cardiothoracic surgeons to minimize operative risks.^[2]^[7] One of the procedure's key benefits is its use of autologous tissue, which eliminates the need for lifelong anticoagulation therapy required with mechanical valve prostheses and allows for unrestricted physical activity, including competitive sports.^[1]^[2]^[3] Long-term outcomes demonstrate excellent survival rates comparable to the general population, low mean transvalvular gradients (around 4 mmHg), and high freedom from valve-related complications, with durability often exceeding 15-20 years.^[1]^[3] However, potential risks include autograft dilatation leading to neoaortic regurgitation or pulmonary homograft degeneration, which may necessitate reintervention in 10-20% of cases over decades.^[3]^[4] Recovery involves an intensive care unit stay of up to 5 days followed by several months of cardiac rehabilitation, with most patients achieving a high quality of life postoperatively.^[2]^[7]

Clinical Indications

Definition and Purpose

The Ross procedure, also known as the pulmonary autograft or switch procedure, is a cardiac surgical technique in which a diseased aortic valve is replaced with the patient's own pulmonary valve, harvested as an autograft along with a portion of the main pulmonary artery, while the resulting defect in the pulmonary position is reconstructed using a pulmonary homograft (donor valve), or occasionally a xenograft when homografts are unavailable.^[8] First described by Donald N. Ross in 1967, this operation represents the only aortic valve replacement utilizing a living valve substitute derived from the patient's own tissue.^[9] The primary purpose of the Ross procedure is to restore durable, near-physiological aortic valve function in patients with severe aortic valve pathology, leveraging the autograft's biological properties to achieve outcomes superior to those of prosthetic alternatives.^[10] Physiologically, the use of autologous living tissue enables somatic growth in pediatric and young adult patients, optimizes hemodynamics with low transvalvular gradients and effective orifice areas comparable to a native valve, and obviates the need for lifelong anticoagulation, thereby reducing risks of bleeding and thromboembolism associated with mechanical valves.^[8] Additionally, the autograft's viable endothelium confers resistance to structural degeneration and infection under systemic pressures, as the pulmonary valve's thin leaflets adapt well when transposed to the aortic root, provided preoperative anatomy supports this relocation.^[11] This procedure targets conditions such as aortic stenosis or regurgitation, or endocarditis-related damage, with particular efficacy in congenital bicuspid aortic valve disease, where early intervention preserves ventricular function and supports active lifestyles without prosthetic limitations.^[8]^[2] Anatomically, it presupposes a structurally normal pulmonary valve and root, capitalizing on the semilunar configuration shared by both valves: the aortic valve maintains unidirectional flow from the left ventricle to the aorta for systemic circulation, while the pulmonary valve governs flow from the right ventricle to the pulmonary arteries for oxygenation, enabling the autograft's functional integration into the higher-pressure aortic environment.^[8]

Patient Selection Criteria

The Ross procedure is primarily indicated for children, adolescents, and young adults under the age of 50 to 60 years who present with severe aortic valve disease that is unsuitable for repair, such as congenital aortic stenosis or regurgitation.^[12]^[13] These patients typically have isolated aortic valve pathology without significant involvement of the ascending aorta or other cardiac structures, making the procedure a viable option for restoring normal valve function.^[14] It is particularly favorable in cases of bicuspid aortic valve disease, where the native pulmonary valve is structurally normal and suitable for autografting.^[15] Key selection factors include the patient's active lifestyle requirements, strong desire to avoid lifelong anticoagulation associated with mechanical valves, and absence of significant comorbidities that could compromise long-term outcomes.^[13] Candidates must demonstrate good pulmonary valve function, with no evidence of bicuspid or quadricuspid morphology, fenestrations, or prior pulmonary interventions, ensuring the autograft's viability.^[14] The procedure is especially suitable for women of childbearing age planning pregnancy, as it eliminates anticoagulation risks during gestation, and for high-performance athletes seeking optimal hemodynamics and growth potential in pediatric cases.^[12]^[16] Compared to mechanical or bioprosthetic valve replacements, the Ross procedure offers superior long-term durability and quality of life in these young patient groups, with restored survival rates approaching those of the general population and reduced need for reinterventions due to the autograft's adaptive properties.^[13]^[15] This benefit is most pronounced in patients with aortic stenosis and normal aortic root dimensions, where the procedure minimizes valve-related complications over decades.^[16] Selection should occur at high-volume centers with expertise to optimize results.^[12]

Contraindications and Precautions

Absolute Contraindications

The Ross procedure is strictly contraindicated in patients with connective tissue disorders, such as Marfan syndrome, Ehlers-Danlos syndrome, or Loeys-Dietz syndrome, owing to the fragility of the aortic root and the substantially elevated risk of autograft dilatation and subsequent failure. These conditions compromise the structural integrity required for successful autograft implantation and long-term durability.^[8]^[17] Pre-existing pulmonary valve abnormalities, including significant stenosis, severe regurgitation, or hypoplasia, constitute absolute contraindications, as they render the native pulmonary valve unsuitable for harvest and use as an aortic autograft, undermining the procedure's foundational principle. Such anomalies increase the likelihood of inadequate valve function post-implantation and heightened perioperative complications. Large pulmonary valve fenestrations discovered intraoperatively also preclude the procedure.^[8]^[18]^[19] Advanced comorbidities that limit life expectancy or amplify surgical risks also prohibit the Ross procedure, including severe three-vessel coronary artery disease and significant mitral valve disease requiring simultaneous intervention. Autoimmune disorders like systemic lupus erythematosus contraindicate the operation due to accelerated tissue degeneration and immune-mediated graft complications. Active endocarditis is also an absolute contraindication.^[8]^[10] Certain anatomical configurations pose insurmountable technical challenges, such as prior cardiac surgeries that distort access to the pulmonary root and jeopardize autograft integrity or lack of suitable pulmonary autograft (e.g., from prior truncus arteriosus repair or pulmonary atresia).^[17]^[20]

Relative Contraindications

Relative contraindications to the Ross procedure encompass patient characteristics or conditions that elevate the risk of perioperative complications or long-term autograft dysfunction, yet do not preclude the operation entirely if benefits outweigh risks following thorough evaluation, such as echocardiography or multidisciplinary assessment. These factors differ from absolute contraindications, like Marfan syndrome or significant pulmonary valve disease, by allowing potential feasibility with modifications or close monitoring.^[8] Advanced age, particularly in elderly patients over 65 years, represents a relative contraindication due to slower healing, higher comorbidity burden, and reduced long-term durability of the autograft compared to younger cohorts; however, studies demonstrate safety and restored survival in select patients over 50 when performed at experienced centers. Similarly, very young children under 2 years pose technical challenges and higher early mortality rates (up to 17%) from autograft or homograft issues, though outcomes improve with age and careful patient selection. Severe left ventricular dysfunction is also relative, depending on overall candidacy.^[21]^[22] Mild pulmonary abnormalities, such as minor regurgitation or hypertension without overt valve disease, or congenital anomalies like bicuspid or quadricuspid pulmonary valves, are relative contraindications assessable via preoperative echocardiography; these increase autograft stress but have shown acceptable early outcomes in case series with experienced surgeons. Rheumatic valve disease also falls into this category, as active inflammation heightens dysfunction risk, though quiescent cases may proceed with antibiotic prophylaxis. Aortic annular size mismatch and bicuspid aortic valve with associated aortopathy are additional relative factors.^[23]^[8]^[19]^[17] The need for multiple valve interventions is a relative contraindication when the aortic pathology predominates but minor involvement of other valves (e.g., mild mitral regurgitation) exists, as addressing additional pathology concurrently elevates complexity without prohibitive risk; significant concomitant disease, however, shifts to absolute contraindication.^[8]

Surgical Technique

Preoperative Preparation

Preoperative preparation for the Ross procedure involves a comprehensive evaluation to assess surgical candidacy, optimize patient physiology, and ensure procedural safety. Diagnostic imaging plays a central role in evaluating the aortic and pulmonary valves, as well as surrounding structures. Transthoracic echocardiography (TTE) is routinely performed to assess aortic valve pathology, left ventricular outflow tract dimensions, pulmonary valve function, and annular sizes for both valves, guiding autograft suitability. If TTE images are suboptimal, transesophageal echocardiography (TEE) may be employed for enhanced visualization of valvular structures and function. Cardiac computed tomography angiography (CTA) or magnetic resonance imaging (MRI) is essential to delineate aortic root morphology, ascending aorta dimensions (with intervention considered if diameter exceeds 38–40 mm), and coronary artery anatomy to avoid intraoperative complications. These imaging modalities confirm the absence of contraindications such as bicuspid aortic valve with significant root dilation or coronary anomalies that could complicate reimplantation.^[24]^[25] Laboratory testing focuses on identifying and mitigating perioperative risks, particularly in patients with underlying comorbidities. A complete blood count (CBC) evaluates for anemia or infection, while a comprehensive metabolic panel (CMP) assesses renal and hepatic function, electrolytes, and nutritional status via serum albumin levels. Coagulation studies, including prothrombin time (PT) and activated partial thromboplastin time (aPTT), screen for bleeding or thrombotic tendencies, especially important if patients are on preoperative anticoagulation for conditions like atrial fibrillation. Blood typing and crossmatching ensure availability of compatible blood products. Additionally, screening for active infection, such as blood cultures or inflammatory markers if endocarditis is suspected, is critical to rule out contraindications before proceeding. Hemoglobin A1c testing stratifies glycemic control risks in diabetic patients.^[24]^[26] Patient optimization aims to reduce modifiable risk factors and enhance resilience to surgical stress. Smoking cessation is recommended at least 4 weeks prior to surgery to improve pulmonary function, wound healing, and reduce postoperative complications. Weight management through prehabilitation programs is advised for patients with obesity or deconditioning, targeting nutritional optimization and physical conditioning to minimize perioperative morbidity. If patients are on anticoagulants, such as warfarin, these are typically discontinued 3–5 days preoperatively with bridging therapy if high thrombotic risk exists, or reversed with vitamin K/protamine as needed to normalize coagulation. Other measures include fasting after midnight the night before surgery and discontinuation of non-essential medications like antiplatelets under guidance.^[26]^[27]^[28] Multidisciplinary planning coordinates care among specialists to tailor the procedure and obtain informed consent. A team comprising cardiologists, cardiothoracic surgeons, anesthesiologists, and imaging experts reviews imaging, labs, and clinical history to confirm patient selection and discuss alternatives, such as mechanical or bioprosthetic valves, emphasizing the Ross procedure's benefits in avoiding lifelong anticoagulation while noting its technical demands. Informed consent addresses procedure-specific risks, long-term durability, and lifestyle implications, ensuring patient understanding. Preoperative anesthesia evaluation assesses airway, cardiovascular stability, and overall fitness for general anesthesia with endotracheal intubation. Sterility protocols, including chest shaving and skin preparation, are initiated in the holding area to prevent surgical site infections.^[8]^[24]

Autograft Harvest and Implantation

The autograft harvest in the Ross procedure occurs under cardioplegic arrest following aortic cross-clamping and administration of cold cardioplegia solution. The pulmonary artery is mobilized and opened transversely proximal to its bifurcation to inspect the pulmonary valve for any anomalies, after which the pulmonary root is excised en bloc, including the valve leaflets, muscular conduit, and sinuses of Valsalva, while carefully avoiding injury to the left anterior descending coronary artery and its first septal branch.^[8] The right ventricular outflow tract is then incised by dividing the anterior right ventricle and scoring the posterior muscle to facilitate access and complete the harvest, typically preserving a 4-5 mm cuff of right ventricular muscle for support.^[29] Excess infundibular muscle and fat are trimmed from the autograft to ensure a clean preparation without distorting the valve geometry.^[10] Implantation of the pulmonary autograft into the aortic position primarily employs the root replacement technique, which is the most common method and involves transferring the entire pulmonary root. After excising the diseased aortic valve and preparing the aortic annulus, the autograft is anastomosed proximally to the left ventricular outflow tract using interrupted or continuous 4-0 polypropylene sutures, followed by reimplantation of the coronary artery buttons into the corresponding sinuses of the autograft to maintain coronary flow.^[8] The distal end of the autograft is then anastomosed to the ascending aorta, completing the full root replacement and preserving the native sinuses' geometry.^[29] An alternative subcoronary technique sutures the valve portion of the autograft directly into the aortic annulus without transferring the full root, tailoring the cusps to fit within the native aortic sinuses while reimplanting the coronaries separately; this method is less frequently used due to technical challenges.^[10] Technical considerations during implantation emphasize achieving a precise sizing match between the pulmonary autograft and the aortic root, assessed preoperatively via echocardiography to measure annular dimensions and guide any necessary aortic root enlargement if the mismatch exceeds 2-3 mm.^[8] Intraoperatively, Hegar dilators or sizers confirm compatibility to ensure the autograft fits snugly within the native annulus for stability.^[29] Careful dissection and suturing techniques are employed to avoid tension, kinking, or distortion of the autograft, which could compromise valve function or coronary perfusion.^[10] Hemodynamically, the implantation aims to preserve the natural dynamics of the pulmonary root, allowing systolic expansion and diastolic recoil similar to the native aortic root for optimal valve coaptation and reduced shear stress on the leaflets.^[8] This configuration promotes laminar flow through the autograft, minimizing turbulence and endothelial damage that could lead to calcification or regurgitation over time.^[10]

Pulmonary Valve Replacement

Following the harvest of the patient's own pulmonary valve for use as an autograft in the aortic position, the right ventricular outflow tract (RVOT) requires reconstruction with a donor graft to restore pulmonary valve function.^[8] The preferred graft for pulmonary valve replacement is a cryopreserved pulmonary homograft, which serves as the gold standard due to its hemodynamic performance and long-term durability in reconstructing the RVOT.^[30] Alternatives include decellularized allografts, such as the SynerGraft decellularized pulmonary homograft, which reduce immunogenicity and demonstrate lower rates of dysfunction compared to standard cryopreserved options in midterm follow-up.^[31] Bioprosthetic valves, including models like the Carpentier-Edwards PERIMOUNT or Hancock porcine valves, may also be used in select cases, particularly when integrated into valved conduits for enhanced structural support.^[30] Implantation typically employs a full root technique, where the homograft or allograft is trimmed and placed as a root replacement or conduit within the RVOT.^[32] The proximal anastomosis is secured to the RVOT muscular infundibulum using running 4-0 polypropylene sutures, with care taken to place shallow bites to avoid injury to the first septal perforator artery; interrupted pledgeted sutures may be added for hemostasis if needed.^[32] The distal anastomosis connects the graft to the pulmonary artery bifurcation with continuous 5-0 polypropylene sutures, ensuring a tension-free alignment.^[30] Sizing involves selecting the largest available homograft that matches the patient's age and anatomy to minimize pressure gradients, with conduit diameters typically ranging from 18 to 26 mm in adults based on the distal pulmonary artery dimensions.^[32] Orientation is guided by aligning the commissures of the graft to optimize leaflet coaptation and prevent regurgitation, often marked to correspond with key anatomical landmarks like the reimplanted coronary arteries.^[32] Closure of the procedure includes de-airing the cardiac chambers via antegrade cardioplegia delivery through the new aortic root, followed by testing valve competence with transesophageal echocardiography to assess for gradients or leaks.^[32] Once satisfactory function is confirmed and hemostasis is achieved, the patient is weaned from cardiopulmonary bypass.^[8]

Technique Variations

The inclusion cylinder technique represents a modification of the Ross procedure designed for partial root replacement, particularly in adult patients, where the pulmonary autograft is inserted within the intact native aortic root to provide autologous external support and minimize prosthetic material use. This approach involves transecting the aorta above the sinotubular junction, excising the diseased aortic valve, and securing the autograft proximally with interrupted sutures while preserving the native aortic walls for reinforcement; coronary arteries remain undisturbed, with orifices created in the autograft for anastomosis. To enhance stability and prevent dilation in adults, a Dacron wrap is often applied externally around the autograft, tailored to the annulus size, which reduces autograft failure rates to approximately 5% at 15 years compared to higher rates in unsupported techniques. Long-term results from this method demonstrate 99% freedom from aortic valve reoperation at 15 years, with 98% of patients exhibiting nil, trivial, or mild aortic regurgitation on echocardiography and minimal root enlargement (0.13 mm/year).^[33]^[34] The supported Ross, also referred to as mini-Ross, incorporates external reinforcement to mitigate autograft dilation, a common concern in adolescents and adults where root geometry may predispose to aneurysmal changes. In this variant, a Dacron graft or personalized external aortic root support (PEARS) prosthesis—custom-made to approximately 115% of the pulmonary artery size—is wrapped around the neoaortic root after autograft implantation, anchored to the native structures to stabilize the annulus, sinuses, and sinotubular junction without requiring anticoagulation. This autologous support technique preserves the full-root replacement benefits while addressing late regurgitation risks, showing smaller neoaortic root z-scores at 1- and 3-year follow-ups compared to standard Ross procedures, with reduced reintervention needs (e.g., only 1 case in early cohorts versus 40% in unsupported groups). Intermediate outcomes indicate no early mortality and low regurgitation progression, though long-term durability remains under evaluation.^[35]^[36] Mini-sternotomy approaches offer a less invasive access route for the Ross procedure in select patients with favorable anatomy, such as those without extensive root aneurysms, aiming to reduce postoperative pain, recovery time, and cosmetic impact while maintaining procedural efficacy. Techniques include an L-shaped upper hemisternotomy extending to the left fourth intercostal space or an arrow-shaped incision down to the third intercostal space, allowing cardiopulmonary bypass via proximal aortic arch cannulation and percutaneous femoral venous drainage. The autograft harvest, reinforcement with Dacron if needed, and anastomoses proceed similarly to the standard method, providing adequate exposure to the aortic and pulmonary roots without compromising outcomes in experienced centers performing over 2,000 such procedures. This modification has been successfully applied in young adults, demonstrating feasibility and good hemodynamic results equivalent to full sternotomy.^[37]^[38] Recent innovations in the Ross procedure, emerging post-2020, focus on enhancing right ventricular outflow tract (RVOT) durability and managing long-term complications through advanced materials and hybrid strategies. Decellularized pulmonary homografts (DPH), processed with sodium dodecyl sulfate since the mid-2000s and refined with conical pericardial extensions, have become preferred for RVOT reconstruction, yielding lower peak gradients (β = -2.99 mmHg) and reoperation rates (1.2% at 15 years) compared to cryopreserved homografts (6.8%). These homografts improve late outcomes by reducing dysfunction (12.4% cumulative at 15 years) and enhancing hemodynamics when combined with tailored surgical techniques. Additionally, percutaneous adjuncts, such as balloon dilatation for RVOT stenosis, have gained traction as minimally invasive interventions post-Ross, with successful outcomes in select cases avoiding redo surgery and supporting the procedure's longevity in dynamic patient populations.^[39]00596-X/fulltext)^[14]

Risks and Complications

Perioperative Risks

The Ross procedure, involving pulmonary autograft implantation into the aortic position and subsequent pulmonary valve replacement, carries inherent perioperative risks due to its technical complexity, including dual-valve surgery and coronary artery reimplantation. In experienced centers, overall operative mortality ranges from 0.9% to 1%, with higher rates (up to 2.2%) observed in patients with complex left ventricular outflow tract pathology.^[40]^[41] Morbidity affects approximately 6.6% of patients, encompassing a spectrum of intraoperative and early postoperative events.^[40] Intraoperative risks primarily stem from the surgical technique, such as bleeding during coronary button reimplantation, which may necessitate reoperation in up to 5.9% of cases, particularly in patients with active endocarditis or coagulopathy. Autograft malposition or distortion due to anatomical mismatch between the pulmonary root and aortic annulus can lead to early cusp dysfunction, contributing to rare instances of immediate autograft failure within the first postoperative months. Cardiopulmonary bypass-related complications, including stroke, occur at a low rate of less than 2% overall for the procedure, comparable to or lower than conventional aortic valve replacement in specialized centers.^[42]^[43]^[44] Early postoperative hazards include infection, with endocarditis incidence below 1% in the immediate period, often linked to technical issues or prosthetic components. Arrhythmias, predominantly atrial fibrillation, affect 14.9% to 15.5% of patients and are more common in those with preexisting myocardial abnormalities. Low cardiac output syndrome, resulting from ventricular dysfunction or right ventricular failure post-autograft harvest, accounts for a portion of early deaths and requires vigilant hemodynamic support.^[45]^[46]^[47] Perioperative monitoring with transesophageal and transthoracic echocardiography is essential to assess for autograft or homograft issues, such as peak transaortic gradients exceeding 15 mm Hg or paravalvular leaks, enabling prompt intervention to mitigate hemodynamic instability. In complex cases, mortality escalates due to factors like prolonged bypass times or associated procedures, underscoring the importance of high-volume expertise.^[48]^[49]^[40]

Long-term Complications

The primary long-term complication of the Ross procedure involves failure of the pulmonary autograft, typically manifesting as progressive dilation leading to aortic regurgitation. Autograft dilation occurs in approximately 34% of patients over extended follow-up, with freedom from significant dilation estimated at 82% at 10 years in select cohorts. ^[50] Reintervention for autograft dysfunction, often due to dilation with moderate or severe regurgitation, affects 5-15% of patients at 10 years, rising to 26% at 15 years. ^[41] This risk escalates in cases where the aortic root exceeds 45 mm, with freedom from such dilation dropping to about 72% at 15 years, particularly when associated with preoperative annular dilation or aortic insufficiency. ^[51] Recent studies as of 2024-2025 continue to demonstrate freedom from autograft and homograft reintervention exceeding 80% at 15 years in adult patients.^[52]^[53] Degeneration of the pulmonary homograft in the right ventricular outflow tract represents another key delayed issue, primarily through calcification and stenosis. These changes necessitate reintervention in 10-20% of patients at 15 years, with freedom from homograft reoperation around 92% in adult series but lower in pediatric populations due to accelerated somatic growth and calcification. ^[54] Stenosis predominates as the indication, occurring in up to 71% of homograft reoperations, often requiring percutaneous or surgical intervention. ^[41] Additional long-term adverse events include pseudoaneurysms at suture lines and recurrence of endocarditis, though these are infrequent. Pseudoaneurysms arise in roughly 1-2% of reintervention cases, typically linked to technical factors or infection. ^[41] Endocarditis recurrence affects the autograft or homograft in 7-13% of reoperations, with isolated reports of late prosthetic involvement. ^[41] Risk factors for autograft complications notably include younger age at surgery, which paradoxically heightens dilation risk (with freedom from dilation as low as 42% at 7 years in younger patients) yet may enhance adaptive remodeling and overall durability in pediatric cases. ^[55] ^[56]

Recovery and Follow-up

Immediate Postoperative Care

Following the Ross procedure, patients are transferred to the cardiothoracic intensive care unit (ICU) for close monitoring, utilizing standard American Society of Anesthesiologists monitors, an intra-arterial catheter for continuous blood pressure assessment, and central venous pressure measurement via a 9Fr introducer catheter.^[24] Near-infrared spectroscopy cerebral oximetry is employed as part of the protocol to evaluate cerebral perfusion.^[24] Hemodynamic stability is prioritized through administration of magnesium sulfate (2 g intravenous bolus) immediately after cross-clamp removal to facilitate sinus rhythm restoration and mitigate reperfusion injury.^[24] Hypertension is aggressively managed with agents such as nicardipine or labetalol to target systolic blood pressure between 90 and 110 mmHg and heart rate between 60 and 80 beats per minute, thereby supporting autograft adaptation and reducing stress on the neo-aortic root.^[24] Beta-blockers are initiated as first-line therapy to control blood pressure and minimize the rate of pressure change (dP/dt) across the autograft.^[16] Mechanical ventilation weaning occurs rapidly, with patients typically extubated within 6 hours postoperatively under enhanced recovery after surgery (ERAS) protocols, which have been shown to shorten ICU stays by up to 10.5 hours and overall hospital stays by a median of 19.4 hours.^[24] In standard practice, ventilator weaning begins the same evening, with extubation the following morning.^[8] Sedation in the ICU is maintained with propofol or dexmedetomidine to facilitate this process while ensuring patient comfort.^[24] Pain control involves multimodal analgesia, including intravenous opioids such as fentanyl or hydromorphone, supplemented by methadone (0.1–0.4 mg/kg) and intravenous acetaminophen (1 g administered post-sternal closure).^[24] Regional techniques, such as erector spinae plane blocks, may be considered but are not routinely used.^[24] Diagnostic evaluations commence immediately after separation from cardiopulmonary bypass with transesophageal echocardiography to confirm autograft and homograft function, including valve competency and gradient assessment.^[8]^[24] Transthoracic echocardiography is repeated serially during the hospital stay and prior to discharge to monitor for early dysfunction or root dilatation.^[8] Chest X-rays are performed routinely to detect pleural effusions, pneumothorax, or other thoracic complications.^[8] Thromboprophylaxis is tailored to the procedure's use of biological valves, obviating the need for long-term anticoagulation; however, short-term measures such as low-dose aspirin or nonsteroidal anti-inflammatory drugs for 6 months may be employed to address homograft inflammation and prevent thromboembolism, with reported rates as low as 0.16% per year.^[8]^[57]^[24] Early mobilization is encouraged within ERAS frameworks to mitigate risks such as pneumonia and deep vein thrombosis, typically beginning with assisted ambulation on postoperative day 1 once hemodynamically stable.^[24] Strict blood pressure control, targeting systolic values below 110–115 mmHg for the initial 6–12 months, is emphasized during this phase to promote autograft remodeling and is facilitated through telehealth monitoring where available.^[10]^[16] This acute management transitions to outpatient surveillance for sustained valve durability.^[10]

Long-term Monitoring

Following the Ross procedure, patients require lifelong surveillance to monitor for autograft dilation, regurgitation, and homograft dysfunction, as these can lead to reintervention and impact long-term valve durability. This ongoing assessment builds on immediate postoperative care by shifting to outpatient protocols that emphasize serial imaging and clinical evaluation to detect subclinical changes early.^[10]^[58] The standard follow-up schedule includes clinical examinations every 6 months and annual transthoracic echocardiography to evaluate valve function and root dimensions.^[58] Additional stress testing, such as exercise echocardiography, is recommended every 2-3 years to assess functional capacity and hemodynamics under load, particularly in active young adults.^[10] For patients with ascending aorta diameters exceeding 45 mm, magnetic resonance imaging (MRI) or computed tomography (CT) is advised every 2-3 years to quantify dilation more precisely.^[58] Key parameters tracked during these evaluations include autograft dimensions (e.g., neo-aortic root diameter), transvalvular gradients (mean and peak), degree of aortic regurgitation (graded as none, trivial, mild, moderate, or severe), and homograft function (pulmonary gradients and insufficiency).^[10]^[58] Echocardiographic measurements focus on sinus of Valsalva and sinotubular junction diameters, with serial comparisons to baseline to identify progressive changes, such as root enlargement or gradient increases beyond 20 mm Hg.^[10] Reintervention is triggered by severe autograft dilation (e.g., neo-aortic root ≥50 mm), rapid growth rates exceeding 5 mm/year, moderate-to-severe regurgitation, or symptomatic dysfunction; homograft issues prompt reoperation if accompanied by right ventricular dilation or symptoms like dyspnea.^[10]00374-9/fulltext) These thresholds guide decisions for valve-sparing root replacement or conduit procedures to preserve the autograft when feasible.^[10] Lifestyle recommendations include endocarditis prophylaxis per American Heart Association guidelines due to the prosthetic homograft, with antibiotic premedication for dental and invasive procedures.^[10] Strict blood pressure control (systolic <110-120 mm Hg) is advised for the first 6-12 months postoperatively using beta-blockers to minimize wall stress on the autograft, transitioning to lifelong hypertension management thereafter.^[10]^[53] No routine exercise restrictions are imposed for asymptomatic patients, though high-intensity activities may be limited if autograft dilation or regurgitation is detected.^[10]

Outcomes and Epidemiology

Survival Rates and Valve Durability

Clinical studies demonstrate high survival rates following the Ross procedure, with 10-year survival ranging from 94% to 95% and 20-year survival approximately 90% in recent analyses.^[59]^[53] A 2025 multicenter study of 252 patients reported 94.3% survival at 10 years and 90.3% at 20 years, comparable to outcomes with mechanical valve replacement.^[59] The Cleveland Clinic's 30-year experience, updated in 2025, showed 94% survival at 10 years, approaching age-matched general population rates and reflecting restoration of near-normal life expectancy as noted in EACTS consensus statements.^[53]^[60] Autograft durability is a key strength of the procedure, with freedom from reoperation typically 80-90% at 15 years in adults, though rates vary by patient group. A 2025 Cleveland Clinic analysis reported 89% freedom from autograft reintervention at 10 years, declining to 72% at 25 years, with stable function evidenced by low mean transvalvular gradients of 4.4 mm Hg at 20 years.^[53] A systematic review and meta-analysis confirmed annual autograft reintervention rates of 0.83% in adults, yielding a lifetime risk of approximately 49% for a 45-year-old, lower than the 94% lifetime risk in children due to somatic growth demands on the autograft.^[57] Thus, durability is generally superior in adults compared to children, where reintervention is more frequent to accommodate growth.^[57] The Ross procedure enhances quality of life through low overall reintervention needs and superior hemodynamics relative to prosthetic alternatives. Long-term reintervention rates for the autograft are around 20-30% by 20 years in adults, contributing to event-free survival superior to bioprosthetic or mechanical valves.^[45]^[53] Patients report improved health-related quality of life, with 2025 Cleveland Clinic data showing significantly higher mental health scores (PROMIS-10: 53 vs. normative 50) and better global emotional function than those with other heart disease (MacNew scores, P<.0001).^[53] Hemodynamics remain excellent, with minimal regurgitation progression and low risks of thromboembolism (0.15% per patient-year) and bleeding, avoiding lifelong anticoagulation.^[45]^[53] Outcomes are influenced by surgeon experience and patient age, with endocarditis occurring at low long-term rates. Procedures performed after 2000 at high-volume centers like the Cleveland Clinic showed no operative deaths and improved durability, attributing gains to refined techniques and standardization.^[53] Younger age at surgery correlates with higher right ventricular outflow tract reintervention needs but does not adversely affect overall survival; autograft risks increase with larger preoperative aortic annulus.^[45] Endocarditis rates are approximately 0.36% per patient-year, roughly half that of mechanical valves, resulting in less than 5% cumulative incidence over 15 years in meta-analyses.^[45]^[57]

Procedure Prevalence and Trends

The Ross procedure remains relatively uncommon in the overall landscape of aortic valve replacements, accounting for less than 1% of all such surgeries in the United States and Europe as of 2025 estimates, though its utilization is notably higher in specialized high-volume centers. For instance, Mount Sinai Hospital in New York performs over 100 Ross procedures annually, representing the largest program worldwide. Globally, a 2025 survey of cardiothoracic surgeons indicated that 74% of respondents perform the procedure, with 75% conducting between 5 and 30 cases per year, highlighting its concentration in expert centers rather than widespread routine practice.^[61]^[62] Geographic variations show higher adoption rates in Europe compared to North America for young patients. In North America, utilization has been lower historically but is increasing, particularly among adults aged 60 or younger, rising from 0.9% of all aortic valve replacements in 2017 to 7.2% by 2023.^[63] Pediatric cases demonstrate further growth, with the Ross procedure serving as a preferred option in congenital heart disease centers across both regions due to its potential for somatic growth accommodation.^[63] Recent trends indicate a resurgence in the Ross procedure since 2020, fueled by accumulating long-term outcome data demonstrating superior durability and quality of life compared to mechanical or bioprosthetic alternatives. This revival is evidenced by a global increase in procedure volumes over the past decade, with North American centers showing the most pronounced uptick in adult applications. The European Association for Cardio-Thoracic Surgery (EACTS) Expert Consensus Statement released in October 2025 has further accelerated adoption, endorsing the procedure for adults under 50 years with severe aortic stenosis or regurgitation, emphasizing patient selection and surgical expertise to optimize results.^[61]^[63]^[60] Despite these advances, barriers to broader implementation persist, primarily stemming from the procedure's technical complexity, which requires specialized training and multidisciplinary teams, limiting its availability outside high-volume institutions. Lack of surgeon experience is cited as the leading reason for non-adoption by 68% of non-performing surgeons in recent surveys. Looking forward, the integration of bioengineered pulmonary valve grafts holds promise for expanding access, as these constructs could enhance right ventricular outflow tract durability and reduce reintervention rates, potentially driving further growth in both pediatric and adult populations.^[62]^[64]^[10]^[65]

History and Development

Origins and Early Adoption

The Ross procedure, a surgical technique for aortic valve replacement using the patient's own pulmonary valve as an autograft, was first proposed in 1962 by Donald Ross, a pioneering British cardiac surgeon. Ross drew on his prior experience with aortic homografts and observed the structural similarities and adaptability of the pulmonary valve, which could potentially grow, resist infection, and avoid the need for lifelong anticoagulation when transplanted to the aortic position. This innovative concept aimed to overcome the limitations of mechanical and bioprosthetic valves available at the time, particularly for younger patients requiring durable, living tissue substitutes.^[66] The procedure was initially implemented in 1967 by Ross himself at Guy's Hospital in London, marking the world's first successful pulmonary autograft aortic valve replacement. In its inaugural description, the technique employed a subcoronary implantation method, where the pulmonary valve was excised and precisely tailored to fit within the existing aortic root without full root replacement, followed by reconstruction of the pulmonary outflow tract using an aortic homograft. Early postoperative outcomes in the initial cohort of 12 patients were promising, with no autograft regurgitation observed in survivors and short-term follow-up indicating hemodynamic stability, though two unrelated deaths occurred. This debut established the feasibility of using autologous tissue for aortic repair but highlighted the technical precision required. Ross continued to refine and advocate for the procedure until his death in 2014.^[67]^[68] During the 1970s, however, the procedure faced significant hurdles that tempered enthusiasm among surgeons. High failure rates emerged, largely attributed to progressive autograft dilation and resultant aortic insufficiency, often linked to the subcoronary approach's inability to fully stabilize the autograft within the higher-pressure aortic environment. These complications led to reoperations in a notable proportion of cases and fostered widespread skepticism regarding the procedure's long-term viability, restricting its use predominantly to pediatric populations where growth potential and lower systemic pressures offered relative advantages. By the 1980s, renewed interest propelled broader adoption across the United States and Europe, driven by refinements such as the full root replacement technique. This evolution allowed for more secure anchoring of the pulmonary autograft within a composite root, mitigating dilation risks and improving durability, which encouraged experienced centers to expand indications beyond children to select adult patients. These advancements marked a pivotal shift, transforming the Ross procedure from an experimental option into a more standardized intervention in specialized cardiac surgery programs.

Key Milestones and Recent Advances

In the 1990s, surgeons shifted toward the full root replacement technique for the Ross procedure to better address autograft dilation, a common issue with earlier subcoronary methods, thereby improving long-term valve stability and hemodynamics.^[69] This evolution marked a pivotal refinement, as the total root approach more closely mimicked native aortic anatomy and reduced the incidence of late insufficiency compared to inclusion or subcoronary implantation.^[70] During the 2000s, Gebrine El Khoury and colleagues introduced the inclusion technique, which embeds the pulmonary autograft within a Dacron graft to provide external support and minimize root dilatation, particularly beneficial for patients with larger aortic annuli.^[71] This method, incorporating the "El Khoury tongue technique" for coronary reimplantation, enhanced surgical precision and reduced prosthetic material exposure, leading to favorable mid-term outcomes with low reoperation rates in selected cases.^[72] The 2010s saw the establishment of long-term registries, such as the international Ross Registry, which provided robust 20-year survival data exceeding 90% in many cohorts, comparable to age- and sex-matched populations, underscoring the procedure's durability in young patients.^[73] Concurrently, there was expanded application to adults, driven by evidence of restored life expectancy and reduced valve-related complications, prompting a resurgence in its use for middle-aged individuals beyond pediatric cases.^[74] In the 2020s, the European Association for Cardio-Thoracic Surgery (EACTS) issued a 2025 expert consensus statement endorsing the Ross procedure as a first-line option for selected young and middle-aged adults with non-repairable aortic valve disease, citing its superior hemodynamics and freedom from anticoagulation.^[60] Recent studies have highlighted the benefits of decellularized homografts for the right ventricular outflow tract, showing slower gradient progression and lower reintervention rates up to 15 years compared to conventional grafts.^[39] Long-term follow-up data indicate approximately 83% survival at 25 years, with autograft durability often exceeding 80% freedom from reoperation, affirming its role in achieving near-normal valve function over decades.^[45] As of late 2025, studies such as one from Mount Sinai continue to affirm excellent long-term outcomes, with survival rates comparable to the general population in younger patients.^[75] Looking ahead, ongoing research emphasizes minimally invasive approaches, such as transcatheter delivery, combined with tissue-engineered homografts to further enhance accessibility and longevity, potentially reducing reinterventions while preserving growth potential in younger patients.^[65]

Etymology and Terminology

Origin of the Name

The Ross procedure is named in honor of Donald N. Ross, the British cardiac surgeon who pioneered and first performed it in 1967.^[9] This nomenclature recognizes his landmark publication in The Lancet, where he detailed the technique of replacing the aortic valve with the patient's own pulmonary autograft, marking a significant advancement in biological valve replacement.^[9] Common alternative terms include pulmonary autograft aortic valve replacement and Ross operation, emphasizing the procedure's use of autologous tissue.^[2] The naming reflects the mid-1960s era of rapid innovation in cardiac valve surgery, which followed the introduction of mechanical prostheses like the Starr-Edwards ball valve in 1960 and sought living tissue alternatives to mitigate issues such as thrombosis and the need for lifelong anticoagulation. In the context of the Ross procedure, an autograft refers to the transplantation of the patient's own pulmonary valve and associated root into the aortic position, serving as a living replacement for the diseased aortic valve and leveraging the tissue's compatibility to promote long-term durability.^[8] A homograft, also known as an allograft, is a human donor-derived valve, commonly used to reconstruct the right ventricular outflow tract after the pulmonary autograft is harvested during the Ross procedure.^[76] In aortic valve surgery, homografts provide a biological alternative but may require eventual replacement due to degeneration.^[77] A bioprosthesis denotes a valve prosthetic derived from animal tissue, such as porcine or bovine pericardium, which is fixed and treated to mimic native valve function; it is frequently compared to the Ross autograft as a non-autologous option for aortic valve replacement, offering freedom from anticoagulation but with limited longevity.^[11] The Ross procedure employs distinct implantation approaches, including root replacement, where the entire pulmonary root is excised and anastomosed as a freestanding unit in the aortic position to fully replace the aortic root, versus the subcoronary technique, which implants the pulmonary valve leaflets directly into the native aortic root without excising the surrounding muscular wall.^[69] The root replacement method has become predominant due to its reproducibility and reduced risk of autograft distortion.^[78] Bicuspid aortic valve (BAV) is a congenital anomaly in which the aortic valve consists of two cusps rather than the typical three, representing the most common cardiac malformation and a frequent precursor to aortic stenosis or regurgitation that may warrant the Ross procedure in younger patients to address early-onset valve pathology.^[79] This condition predisposes individuals to accelerated valve degeneration and associated aortopathy, influencing surgical timing and technique selection.^[80]

Broader Applications

Societal and Ethical Considerations

The Ross procedure's technical complexity and requirement for advanced surgical expertise limit its availability primarily to high-volume cardiac centers, creating barriers to access for many patients seeking aortic valve replacement. In the United States, for instance, only a small number of academic institutions perform a substantial volume of these operations annually, making it challenging for patients in remote or underserved regions to receive the procedure. This concentration exacerbates healthcare disparities, as evidenced by studies showing reduced access to complex aortic valve interventions in socioeconomically disadvantaged areas with higher Area Deprivation Index scores.^[81]^[82] Ethical considerations surrounding the Ross procedure revolve around balancing its resource-intensive demands— including specialized facilities, multidisciplinary teams, and long-term follow-up—against demonstrated long-term benefits like improved survival rates comparable to the general population and avoidance of lifelong anticoagulation. Informed consent processes must thoroughly address the risk of reoperations, which affect approximately 20% of patients over 20 years due to autograft or conduit issues, ensuring patients understand these potential future interventions despite the procedure's overall durability. These debates highlight the need for equitable resource allocation in cardiac care, particularly for young adults with congenital or degenerative valve disease who stand to gain the most from its hemodynamic advantages.^[83]^[84]^[85] Patient advocacy organizations focused on congenital heart disease provide essential support for individuals undergoing the Ross procedure, fostering peer-to-peer networks, educational resources, and discussions on quality-of-life impacts such as enhanced physical activity and psychological well-being post-surgery. Groups like the Adult Congenital Heart Association emphasize holistic care, including mental health and transition to adult services, which are critical given the procedure's role in extending active lifestyles for pediatric and young adult patients. Recent policy efforts, including the 2025 EACTS Expert Consensus Statement, advocate for standardized training programs and multidisciplinary protocols to broaden availability and address implementation barriers in diverse healthcare settings. Specialized courses, such as the Ross Master Course, further promote surgeon education to expand safe adoption beyond elite centers.^[86]^[87]^[60]^[88]

Use in Veterinary Medicine

The Ross procedure has been adapted for veterinary medicine primarily in experimental contexts to model treatments for congenital heart defects, including pulmonic stenosis and aortic defects, using animals such as dogs, pigs, and sheep. Early feasibility studies in dogs during the 1960s established the viability of pulmonary valve autotransplantation to the aortic position, demonstrating sustained autograft function under systemic pressure with follow-up durations reaching 12 months.^[89] These models replicate aspects of pediatric cases seen in veterinary cardiology, where such defects are common in breeds like Bulldogs and Boxers for pulmonic stenosis. Clinical application remains rare, particularly in small animals like dogs and cats, due to anatomical challenges and preference for less invasive interventions like balloon valvuloplasty; use in larger animals is similarly limited to research rather than routine practice.^[90] Techniques in veterinary models adhere to the core autograft principle—harvesting the animal's own pulmonary valve for aortic replacement—but are simplified to suit species-specific anatomy, such as shorter vascular lengths in dogs or rapid growth in pigs. Homografts are infrequently employed owing to sourcing difficulties and ethical considerations in veterinary settings, with synthetic or decellularized alternatives sometimes tested instead. In sheep models, for example, the procedure involves a left thoracotomy, cardiopulmonary bypass, and implantation of the autograft as a freestanding root using continuous sutures, avoiding full sternotomy to reduce operative stress.^[89] Pigs present additional adaptations for their thicker chest walls and higher metabolic demands, focusing on interposition grafts to study dilatation.^[89] Outcomes in these veterinary applications indicate enhanced short-term survival in simulated pediatric scenarios, with autografts showing adaptive remodeling, though comprehensive long-term data are constrained by study durations and animal ethics. In canine experiments, autografts maintained structural integrity without immediate failure, supporting their potential for defect correction. Ovine models report 58.8% survival beyond the initial postoperative period, with 6-month echocardiography revealing moderate root dilatation (mean 15-20%) but preserved leaflet viability and neo-vascularization on histology.^[89] Limited follow-up in pigs highlights progressive growth adaptation, with no acute thrombosis but risks of right ventricular strain in larger specimens.^[89] Veterinary research leveraging the Ross procedure has informed human advancements, including studies on age-related extracellular matrix changes in porcine pulmonary valves, which provide insights into remodeling processes for developing tissue-engineered heart valves suitable for procedures like the Ross procedure. As of 2025, applications in veterinary medicine remain predominantly experimental, with ongoing research focusing on tissue-engineered alternatives in large animal models.^[91]^[92]

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