Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure

Jamie L R Romeo, Grigorios Papageorgiou, Francisco F D da Costa, Hans H Sievers, Ad J J C Bogers, Ismail El-Hamamsy, Peter D Skillington, Rochelle Wynne, Stefano Mastrobuoni, Gebrine El Khoury, Johanna J M Takkenberg, Mostafa M Mokhles

Research output: Contribution to journalArticleAcademicpeer-review


Importance: There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed.

Objective: To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure.

Design, Setting, and Participants: A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018.

Main Outcomes and Measures: Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling.

Results: During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13 015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year).

Conclusions and Relevance: Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.

Original languageEnglish
Pages (from-to)539-548
Number of pages10
JournalJAMA Cardiology
Issue number5
Publication statusPublished - 1 May 2021


  • Adolescent
  • Adult
  • Aged
  • Aortic Valve Disease/surgery
  • Aortic Valve Insufficiency/surgery
  • Bicuspid Aortic Valve Disease/surgery
  • Cardiac Surgical Procedures/methods
  • Echocardiography
  • Female
  • Hospital Mortality
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Pulmonary Artery/transplantation
  • Pulmonary Valve/transplantation
  • Retrospective Studies
  • Survival Rate
  • Transplantation, Autologous/methods
  • Young Adult


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