Use of the Ross Procedure in North America: Relation Between Surgical Volume and Operative Mortality

There has been a renewed interest in the Ross procedure as an alternative to conventional aortic valve replacement in young adults.

This study aimed to assess contemporary trends in Ross procedure utilization in adults and examine the relationship between surgical volumes and operative mortality.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients who underwent the Ross procedure between 2008 and 2023. We used modified Poisson regression with generalized estimating equations and robust standard errors to assess the relationship between Ross volumes and operative mortality, accounting for clustering by center and year.

A total of 2,268 Ross procedures were reported across 194 centers from 2008 to 2023. The median age was 43 years (Q1-Q3: 32-52 years). The median number of procedures per center over 16 years was 2 (Q1-Q3: 1-7). Ross procedure utilization reached a nadir in 2017 (n = 63) before increasing annually, reaching 531 cases in 2023. Ross procedures represented 0.9% of all aortic valve replacements in adults ≤60 years of age in 2017, increasing to 6.7% by 2023. Operative mortality declined from 4.4% in 2008 to 1.0% in 2020 but rose to 2.5% in 2023. Regression-adjusted modeling demonstrated an association between higher center- and surgeon-level Ross volume and lower operative mortality (P < 0.001), with substantial improvements occurring beyond approximately 10 cases per year.

The Ross procedure is increasingly utilized in North America. Outcomes appear more favorable in higher-volume centers and surgeons, supporting the view that experience may play a key role in achieving optimal results. These findings highlight important considerations for how Ross programs are developed and implemented.