The Ross Renaissance: Trends and Short-Term Outcomes of the Ross Procedure in the United States

The Ross procedure, involving pulmonary autograft replacement of the aortic valve, has remained underutilized. Recent technical advancements have prompted renewed interest in the Ross operation, particularly as an alternative to conventional surgical aortic valve replacement (SAVR).

The purpose of this study was to examine national utilization of the Ross procedure over the last decade and evaluate associated feasibility, safety, and cost, relative to SAVR.

We identified adult and pediatric patients undergoing elective aortic valve replacement within the 2010-2022 Nationwide Readmissions Database. Ross and SAVR patients were age-matched using coarsened exact matching. Subsequently, multivariable regression was used to compare clinical outcomes, 30-day readmissions, and resource utilization between groups. The primary endpoint was a composite of in-hospital mortality, stroke, prolonged mechanical ventilation, reoperation, acute kidney injury, sepsis, cardiac arrest, and venous thromboembolism.

Among 109,235 valve replacements, Ross procedures constituted 1.5% of adult and 37.2% of pediatric cases. Utilization increased significantly over time across age groups (P < 0.001). Compared to SAVR, Ross recipients were younger, with fewer comorbidities, and often treated at high-volume teaching hospitals. After age-matching and risk adjustment, the Ross approach was associated with lower odds of composite complications (adjusted OR: 0.65; 95% CI: 0.46-0.91), particularly stroke (adjusted OR: 0.38; 95% CI: 0.18-0.80), as well as lower nonhome discharge and 30-day readmissions. Hospitalization costs were not significantly different between groups.

The Ross procedure is undergoing a resurgence in pediatric and adult populations, with favorable short-term outcomes and comparable costs to SAVR. These findings support broader adoption of the Ross operation at experienced centers for appropriately selected patients.