What is the role of the Ross procedure in today's armamentarium?

The Ross procedure, which consists of replacing the aortic root with a pulmonary autograft, is the only surgery that ensures long-term viability of the aortic valve substitute. The presence of a living valve in the aortic position was theorized to translate into improved clinically relevant outcomes. This has now been confirmed by a number of recently published studies, which highlight the benefits associated with this surgery in terms of survival, quality of life, hemodynamic characteristics, and freedom from valve-related complications. Nevertheless, despite the evidence, the Ross procedure remains largely underused and has even been abandoned by a large number of groups based on some real and sometimes justifiable concerns, and a number of unfounded biases. The aim of this article is to provide a comprehensive, evidence-based review of the current literature pertaining to the Ross procedure, with an emphasis on the rationale, results, technical key points, alternatives, and future directions.