The Ross Procedure: Determinants of Long-Term Durability

Sex-related differences in valvular heart disease are increasingly recognized, yet contemporary Ross procedure literature rarely reports outcomes by sex. Given the marked male predominance in published series, whether outcomes differ by sex remains unknown. This study evaluated sex-specific outcomes following the Ross procedure in a high-volume center.

This retrospective cohort study included adults undergoing pulmonary autograft using a full root technique between 2011 and 2025. Propensity score matching (2:1 male: female) was performed using 24 preoperative variables. Primary outcomes were overall survival and freedom from reintervention. Secondary outcomes included aortic regurgitation (AR ≥ grade 2), pulmonary regurgitation (PR ≥ grade 2), New York Heart Association (NYHA) functional class, and longitudinal echocardiographic changes.

Among 816 patients, 512 matched individuals (337 male, 175 female) were analyzed. Early outcomes were similar, including 30-day mortality (0.6% male vs 1.1% female). Estimated ten-year survival was excellent in both groups (96.4% male vs 92.9% female, P=0.410), as were reintervention rates (10-year cumulative incidence 5.0% vs 2.7%, P=0.309). In contrast, females exhibited two-fold higher AR progression (10-year incidence 11.0% vs 20.5%, P=0.005), supported by generalized estimating equations (sex-by-time P=0.039) and Cox regression (adjusted hazard ratio 2.16-3.00). Pulmonary regurgitation progression and autograft/homograft hemodynamics were similar. Females had persistently worse NYHA functional class throughout follow-up.

While survival and reintervention rates after the Ross procedure are comparable between sexes, women experience significantly greater aortic regurgitation progression and worse functional status. These findings underscore important sex-specific differences in postoperative remodeling and mid- to long-term outcomes.