Landmark study confirms long-term durability of Ross procedure for aortic valve replacement

The Ross procedure, a highly specialized option for aortic valve replacement, is associated with significant long-term durability and excellent outcomes in a wide range of adult patients with aortic valve disease. These are the results from a new landmark study, led by world-renowned Mount Sinai heart surgeon, Ismail El-Hamamsy, MD, PhD, the Director of Aortic Surgery for Mount Sinai Health System, and published June 23 in the Journal of the American College of Cardiology (JACC).

This landmark publication represents the largest North American study ever conducted on the Ross procedure. Findings from this contemporary cohort establish a benchmark for the durability of this specialized operation when performed by experienced surgeons using a tailored surgical technique at high-volume centers of excellence. The study confirms the unique role of the Ross procedure in adults and further challenges long-held conceptions around the operation. The findings suggest that the Ross procedure should be considered for a broader group of appropriately selected patients, including adults over 50 and patients with aortic regurgitation-groups traditionally considered less suitable candidates.

The Ross procedure is the only aortic valve replacement operation that has consistently been shown to restore life expectancy to that of the general population matched for age and sex. This comprehensive longitudinal study highlights the unique advantages of the Ross procedure in adults, including outstanding valve durability and excellent long-term clinical outcomes. Importantly, our findings challenge longstanding assumptions by demonstrating excellent results in patient groups that have historically been overlooked."

Dr. El-Hamamsy, the Randall B. Griepp, MD Professor of Cardiovascular Surgery, Icahn School of Medicine

The Ross procedure replaces a patient's diseased aortic valve with their own pulmonary valve, which closely mirrors the structure and function of a healthy aortic valve. Unlike conventional aortic valve replacement using tissue or mechanical valves, the Ross procedure provides a living autologous valve in the aortic position. Through adaptation, the valve can replicate the biological and hemodynamic properties of the native aortic valve. These unique characteristics contribute to improved long-term outcomes compared with biological or mechanical valves.

Mechanical valves offer durability but require lifelong anticoagulation and associated lifestyle restrictions. Biological valves avoid anticoagulation but often deteriorate over time, particularly in younger patients. In either case, the aortic valve is replaced by a non-living substitute with no ability to repair, adapt or grow. In contrast, the Ross procedure offers a living pulmonary valve in the aortic position, resulting in physiologic valve function, excellent durability and normal quality of life.

"The fundamental advantage of the Ross procedure is that it restores a living valve to the aortic position," explains Dr. El-Hamamsy. "That distinction translates into unique long-term benefits for patients."

Historically, the Ross procedure has been performed most commonly in adults younger than 50 with no aortic regurgitation - a condition where the aortic valve does not close adequately, allowing blood to leak backward from the aorta into the main pumping chamber of the heart (the left ventricle), forcing it to work harder. In these patients, the Ross procedure was traditionally associated with less durability of the pulmonary valve.

The study followed 455 adults who underwent the Ross procedure between 2011 and 2019. All procedures were performed by Dr. El-Hamamsy and his team. Patients participated in a dedicated follow-up program that included regular clinical evaluations and annual echocardiograms. The mean patient age was 48. Half the cohort were older than 50; 10 percent were older than 60, with the oldest patient being 67.

At 12 years after surgery, survival was equivalent to that of the general population. More than 96 percent of the patients did not require cardiac reintervention, and more than 98 percent had no significant aortic valve dysfunction. Fewer than 1 percent required permanent pacemaker implantation, substantially lower than rates reported following conventional aortic valve replacement. No patients experienced patient-prosthesis mismatch (this happens when the implanted heart valve is too small relative to a patient's body size), and there were no cases of aortic valve endocarditis. Among the 3.5 percent of patients who required additional intervention within 12 years, most were successfully treated using minimally invasive transcatheter techniques rather than repeat open-heart surgery.

The investigators also compared outcomes between patients with aortic stenosis - a heart valve disease where the aortic valve narrows, restricting blood flow from the heart to the rest of the body, making the heart work harder to pump blood - and those with aortic regurgitation. For the first time, no differences were observed in aortic valve function or need for reintervention at 12 years, opening the way for consideration of the Ross procedure in this patient population. 

"These results demonstrate that use of a tailored surgical approach in patients with aortic regurgitation can eliminate differences in long-term outcomes," Dr. El-Hamamsy says. 

His pioneering work has become the standard of care for the Ross procedure in many centers worldwide. 

"Additionally, our findings showed similar outcomes in patients older than 50, challenging the traditional paradigm of routine use of tissue or mechanical valves in this age group. The combination of excellent durability, restored survival, and normal quality of life is driving renewed consideration for the Ross procedure in older adults."

While the results are encouraging, investigators emphasize that outcomes following the Ross procedure are closely linked to surgeon experience, institutional expertise, and specialized postoperative management.

"These outcomes reflect the work of a dedicated multidisciplinary team and a mature Ross program," said Dr. El-Hamamsy. "The Ross procedure is a technically demanding operation that should be performed in experienced, high-volume centers committed to comprehensive patient care and close follow-up."

Dr. El-Hamamsy, who serves as Director of the Adams Valve Institute at The Mount Sinai Hospital, has performed nearly 1,000 Ross procedures during his career and is internationally recognized as a leader in the field. He has helped launch more than 40 Ross programs in 15 different countries.

As interest in the Ross procedure continues to grow worldwide, researchers are also pursuing advances in tissue-engineered heart valves that may further expand treatment options for patients with aortic valve disease and advance cardiovascular care.