Determinants of Long Term Durability After the Ross Procedure: Insights From a Sex-Based Analysis
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Updated: Aug 13, 2026
A Rodent Model of The Ross Operation: Syngeneic Pulmonary Artery Graft Implantation in A Systemic Position
Published on: April 1, 2022
Nabil Ajmi1, Arman Sarshoghi1, Ismail Bouhout1
1Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Quebec, Canada.
Background:
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 after the Ross procedure in a high-volume center.
Methods:
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 grade ≥2, pulmonary regurgitation (grade ≥2), New York Heart Association Functional Classification, and longitudinal echocardiographic changes.
Results:
Among 816 patients, 512 matched individuals (337 men and 175 women) were analyzed. Early outcomes were similar, including 30-day mortality (0.6% men vs 1.1% women). Estimated 10-year survival was excellent in both groups (96.4% men vs 92.9% women; P = .410), as were reintervention rates (10-year cumulative incidence 5.0% vs 2.7%, P = .309). In contrast, women exhibited 2-fold higher aortic regurgitation progression (≥2+, 10-year incidence 11.0% vs 20.5%; P = .005), supported by generalized estimating equations (sex-by-time P = .039) and Cox regression (adjusted hazard ratio, 2.16-3.00 across models). Pulmonary regurgitation progression and autograft/homograft hemodynamics were similar. Women had persistently worse New York Heart Association Functional Classification throughout follow-up.
Conclusions:
Although survival and reintervention rates after the Ross procedure are comparable between the 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.
