Global Momentum for the Ross Procedure: Now is the Time

Editorial

Managing aortic valve disease is inherently complex given disease heterogeneity, the diversity of patient goals and preferences, and limitations associated with current valve substitutes. ¹

Surgical aortic valve replacement in adults is not curative. ² Whether choosing a mechanical or biological prosthesis, an impaired life expectancy compared with age- and sex-matched populations has been described, particularly in those with aortic insufficiency and age below 60.^2-4 By contrast, patients after the Ross procedure exhibit survival comparable to that of the general population well into the third decade. ⁵ Although such findings must be interpreted cautiously due to selection biases, they have sparked renewed interest in the Ross procedure.

Given a consequential steep increase in Ross procedure utilization after 2017, ⁶ a reevaluation of current global Ross practices seems justified. In this issue of The Journal of the Heart Valve Society, Nam and colleagues diligently examined contemporary Ross practices and standards through an international survey. ⁷ Their survey was returned by 167 cardiac surgeons from 6 continents (60% North America). Of those, 74% perform the Ross procedure, the majority completing 5 to 20 cases/year. Most are in practice >15 years, treat younger adults, and prefer decellularized pulmonary homografts for the right ventricular outflow tract. Substantial variability exists in surgical technique for autograft implantation and external support. While more standardized, postoperative protocols also offer room for harmonization. Interestingly, the Ross procedure is considered for most patient scenarios in the survey, although opinions regarding contraindications are still not uniform. Findings from this survey shed some light on contemporary Ross practices and reveal opportunities for improvement and harmonization.

There are several essential requirements for the continued relevance of the Ross procedure in the future: global access and collaboration, training infrastructure, centralization to centers of excellence, and guidelines recognition ⁸ (Figure 1). Several findings from the current study should be highlighted in view of the above and current discussions.

Figure 1.

Global Momentum for the Ross Procedure.

First and foremost, this study presents a valuable opportunity to initiate discussions around improving worldwide access to the Ross procedure and sharing data and expertise through a global Ross Community and Registry.

Despite its growing reputation as a viable treatment option internationally, ⁹ the Ross procedure remains primarily practiced in the Northern Hemisphere, as reflected in survey demographics and geographical distribution. ⁷ This finding raises questions about equitable access to the Ross procedure. Its current perception as a niche solution for patients with financial resources and geographic reach further underscores a need to democratize access to it. Although the survey by Nam and colleagues inquired about participation in a global Ross Registry, no results were reported in their study, missing an opportunity to assess willingness toward collective data infrastructures. Past efforts, such as an early registry from Ronald Elkins and the Hans Sievers-led European initiative, ultimately did not endure. These experiences underscore the need for sustainable structures to ensure the success of future initiatives. To succeed, future registries must ensure inclusive governance and worldwide representation, while leveraging accessible and interoperable data systems. A truly global Ross Community, committed to not only sharing outcomes but also technical and institutional insights, will be critical for training purposes and quality improvement. Improving transparency of global Ross practices and outcomes, which will be essential in revisiting the role of the Ross procedure in future guidelines, ⁸ starts with harmonization of data structures and outcome definitions. ¹⁰ The Heart Valve Society, with the associated Valve Research Networks, provides excellent starting places to do so.

Secondly, a notable proportion of respondents were introduced to the Ross procedure early in their careers. It is undeniable that the Ross procedure is more technically intricate than prosthetic aortic valve replacement. ¹¹ While long-term evidence backs the Ross procedure and new programs are emerging rapidly, a critical question remains whether it can be taught and scaled successfully.

Several recent studies sought to evaluate its learning curve and the impact of adding new surgeons to established Ross programs on outcomes. The learning curve associated with the Ross procedure is ±75 to 100 cases for an early-career surgeon, ¹² comparable to minimally invasive mitral valve repair. ¹³ Tagliafierro et al looked at 673 Ross procedures between 2011 and 2023, demonstrating that complications decreased over time and adding new surgeons to an experienced program did not compromise outcomes. ¹⁴

Adequate mentorship thus facilitates safe adoption of the Ross procedure, which is supported by the observation that 29% to 51% of respondents learned it during residency or fellowships. On the other hand, this reinforces the need for structured educational programs and peer-to-peer support, which may be facilitated through a Ross Community. Mentorship, fellowships, and rotational exchanges will be key in sharing surgical experience in the future, and referrals must funnel toward programs where consistently safe and durable outcomes are achieved.

Thirdly, the heterogeneity in structural autograft support strategies underscores the need for consensus on personalized surgical techniques. Although most surgeons in this survey utilize full root replacement, vast differences exist in autograft support strategies.

External support of the pulmonary autograft seeks to prevent late neoaortic dilation and insufficiency. Several standardized techniques for the Ross procedure are feasible and proven effective, ⁹ and no single “best” technique has been identified. It makes more sense to tailor existing techniques to individual patients based on factors such as age, valve morphology, hemodynamics (eg, pure aortic insufficiency), and annular/aortic diameter, as well as surgeon preference. ¹⁵ Globally sharing technical pearls and pitfalls could enable us to refine current techniques so we can ultimately match the unique needs of each patient. Such an approach will allow us to further optimize outcomes by personalizing the Ross procedure.

Lastly, indications for the Ross procedure have expanded to now also consider mild pulmonary valve abnormalities, active endocarditis, and even inflammatory conditions. ¹⁶ This is confirmed by the Nam et al study as it shows that the Ross procedure is considered for most of their patient scenarios, although they also reveal ongoing disagreement in surgeon opinions on absolute contraindications. Of note, not a single “risk factor” in their survey is regarded as an absolute contraindication by >61% of surgeons.

Knowledge of contraindications is indeed critical, yet individualized assessment of the most suitable option (including patient values and preferences) is the ultimate goal. This nuance is reflected in the stark contrast between opinions on absolute contraindications (Figure 4) and scenario-driven patient suitability for the Ross procedure (Figure 5) in the work of Nam and colleagues, for example, with regard to younger Marfan syndrome or endocarditis patients.

Rather than focusing on contraindications, we expect the field to move further toward a personalized approach in aortic valve treatment selection. Enhanced global collaboration (ie, Ross Registry) may, however, support more precise identification of contraindications and address unresolved questions, such as male–female differences, alternatives to pulmonary homografts, and the role of the Ross procedure in rheumatic and inflammatory diseases.

The times are changing for the Ross procedure as it reemerges as a therapeutical option for young and active adults with aortic valve disease. We once again stand at the crossroads. Do we let the Ross procedure continue as a niche solution for the happy few or do we expand our educational and data-sharing frameworks so we can tailor it to all who wish for it and stand to benefit from it?

As outlined above, the sustained relevance of the Ross procedure will hinge on several efforts, many of which could be addressed through the launch of a dedicated Ross Community and streamlined Registry to drive safe, broader adoption, and systematic refinement of the operation, globally.