Long-term outcomes of the Ross procedure in 212 consecutive patients (median age 34 years) operated between 1990–2004, comparing freestanding aortic root replacement (n=108) vs. aortic root inclusion (n=104), with a median follow-up of 26.6 years.
30-year survival was 79.4% — 9.1% lower than the age/sex-matched Canadian general population. By 30 years, 22% of patients needed Ross-related reintervention; cumulative autograft reoperation incidence was 19.1%, pulmonary homograft reoperation 17.1%, autograft dysfunction 38.0%, and pulmonary homograft dysfunction 62.6%. Dilated aortic annulus, older age, and freestanding root replacement predicted autograft reoperation.
- Single-center Canadian cohort limits generalizability. - Freestanding root replacement and inclusion techniques were not randomly assigned, introducing selection bias. - Competitive risk of non-Ross mortality may obscure true valve-related event rates.
The Ross procedure offers durable survival for young adults but does not restore normal life expectancy, and both valves show significant deterioration by 30 years — counsel patients about a ~1-in-5 chance of reintervention and rising valve dysfunction over time. Avoid freestanding root replacement and be cautious in patients with a dilated aortic annulus or older age, as these independently predict autograft reoperation.
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