For decades, the Ross procedure has occupied an ambiguous position in adult aortic valve surgery. Although conceptually appealing, replacing a diseased valve with living autologous tissue, its technical complexity and the need to operate on two valve positions simultaneously, particularly in the current “TAVI era,” have limited its widespread adoption. The recent consensus document from the European Association for Cardio-Thoracic Surgery (EACTS) seeks precisely to address this paradox: to synthesize contemporary evidence and define the role of the Ross procedure in adult patients with aortic valve disease.
The document brings together an international panel of experts who performed a systematic review of the literature and formulated recommendations through a structured consensus process. Their objective is to critically assess the available evidence, identify the most appropriate patient population, describe key technical aspects of the operation, and establish recommendations for long-term follow-up.
Beyond a simple narrative review, the document attempts to address a fundamental question: whether the Ross procedure should be considered a valid (and in some cases even preferible) alternative to conventional aortic valve replacement in selected subgroups of adult patients. The central argument of the consensus is based on a straightforward physiological principle: the pulmonary autograft is a living tissue capable of adapting to systemic hemodynamic conditions. Unlike mechanical or biological prostheses, the Ross operation preserves the cellular architecture and dynamic function of the aortic root–left ventricular outflow tract complex. This characteristic has clinically relevant implications. Several observational studies and registries have shown that patients undergoing the Ross procedure may achieve long-term survival comparable to that of the age- and sex-matched general population. From a hemodynamic standpoint, the pulmonary autograft provides very low gradients and essentially eliminates prosthesis–patient mismatch. In addition, the absence of prosthetic material reduces the risk of thrombosis and the establishment of infective endocarditis foci, while also avoiding the need for lifelong anticoagulation.
If the potential outcomes are so favorable, why has the Ross procedure not become the standard technique for young patients? The document itself acknowledges that the answer lies in the technical complexity of the operation. Unlike conventional aortic valve replacement (an operation that is highly standardized and associated with low operative risk in young patients) the Ross procedure requires complete reconstruction of the aortic root and replacement of the pulmonary valve with a homograft. This effectively transforms one operation into two and substantially broadens the spectrum of potential complications, making it more difficult to maintain the favorable risk–benefit balance necessary for surgical indication. In this context, institutional experience plays a decisive role. The literature consistently demonstrates a clear relationship between procedural volume and outcomes. When the Ross procedure is performed in centers with limited experience, perioperative mortality may be up to three times higher than that observed with conventional valve replacement. This reality has historically shaped the cautious recommendations found in clinical practice guidelines, which have limited the Ross procedure to highly selected indications and specialized centers.
One of the most valuable contributions of the document is its effort to more precisely define the profile of the ideal candidate. Traditionally, the Ross operation has been reserved for young adults with aortic stenosis. However, the consensus suggests that the indications may be broader. In general, the procedure should be considered in patients with irreparable aortic valve disease and a life expectancy exceeding 15–20 years. This includes both aortic stenosis and aortic regurgitation, provided that valve repair is not feasible or is expected to have limited durability. From an anatomical perspective, the ideal substrate includes a non-dilated aortic root and an appropriate relationship between the aortic and pulmonary annuli, with the aortic annulus not exceeding 27 mm and remaining proportionate to the pulmonary annulus. In the presence of significant annular dilatation, reinforcement or stabilization techniques may be required to prevent long-term dilation of the autograft. When a discrepancy exists between the annulus receiving the autograft and the sinotubular junction (STJ), the interposition of a Dacron conduit is recommended to preserve the geometry of the autograft and subsequently complete the anastomosis with the ascending aorta, rather than directly connecting the autograft to the native aorta. Interestingly, valve morphology (whether tricuspid, bicuspid, or even unicuspid) appears to have less influence on outcomes than previously assumed when appropriate surgical techniques are employed.
Another traditional argument against the Ross procedure has been the possibility of creating a bivalvular disease. If either the pulmonary autograft or the pulmonary homograft fails, the patient may require reintervention at one or both valve positions. The consensus acknowledges this risk, but indicates that the reintervention rate is acceptable when modern techniques and appropriate patient selection are applied. The main causes of reoperation remain dilation of the aortic autograft and degeneration of the pulmonary homograft. To minimize these complications, strict blood pressure control is recommended, and several technical modifications have been developed, including reinforcement of the autograft using inclusion techniques or external support strategies, which are illustrated in detail within the document. In the case of homograft degeneration, the authors recommend the use of cadaveric grafts rather than porcine xenografts, as well as the consideration of percutaneous treatment options when appropriate. Nevertheless, the document emphasizes that long-term surveillance is essential and should include lifelong clinical and echocardiographic follow-up.
COMMENTARY:
Initiatives from EACTS to produce documents of this nature are particularly welcome. One of the most compelling messages of the consensus is the need for procedural centralization. The accumulated evidence indicates the existence of a significant learning curve. Some studies estimate that approximately 75 cases are required before consistent and reproducible results are achieved. For this reason, the authors advocate the creation of Centers of Excellence dedicated to the Ross procedure—institutions with sufficient procedural volume, audited outcomes, and multidisciplinary teams with specific expertise. This concept reflects a broader trend in cardiac surgery: concentrating complex procedures in highly specialized centers in order to improve patient outcomes.
Despite the enthusiasm conveyed throughout the document, the authors themselves acknowledge a major limitation: the absence of randomized clinical trials directly comparing the Ross procedure with contemporary mechanical or biological prostheses. The only randomized trial available compared the Ross operation with aortic homografts, a strategy that is rarely used today. The most recent attempt to conduct a contemporary randomized study, the REVIVAL trial, was ultimately abandoned due to difficulties in randomization and the limited comparability of surgical expertise among teams assigned to different treatment strategies. Furthermore, a design in which the “Ross arm” included highly experienced surgeons, such as those who authored the consensus, would likely be criticized for limited external validity and poor generalizability to other clinical environments.
The EACTS consensus document likely represents the most comprehensive review to date on the Ross procedure in adult patients. Rather than introducing new data, its principal c00ontribution lies in organizing and reinterpreting the existing evidence to provide a clear conceptual framework.
The final message is nuanced yet clear: in carefully selected young patients and when performed in experienced centers, the Ross procedure may provide clinical and hemodynamic outcomes superior to those achieved with prosthetic valve replacement. However, this conclusion does not imply that the Ross operation should become the universal strategy for aortic valve replacement. Its technical complexity, the requirement for dedicated expertise, and the uncertainty regarding certain aspects of long-term durability remain important limiting factors. Ultimately, the document seems to advocate an intermediate model: the Ross procedure not as a surgical curiosity reserved for a handful of enthusiasts, but neither as a universally applicable technique. Rather, it should be considered a highly specialized strategy that (when performed by expert teams and in appropriately selected patients) can offer something no prosthetic valve fully replicates: a living valve.
REFERENCE:
Vojacek J, Gofus J, Andreas M, Bavaria JE, Berdajs D, Casselman FPA, et al.; EACTS Scientific Document Group. EACTS Expert Consensus Statement on the Ross Procedure in Adult Patients. Eur J Cardiothorac Surg. 2026 Feb 5;68(2):ezaf295. doi:10.1093/ejcts/ezaf295.
