Autologous is the best.

In this issue, Andreas et al. [1] and da Costa et al. [2] present their centre's experience with the Ross procedure. In both publications and up to 18 years postoperatively, patient survival after the Ross operation was comparable with that of the general population and was superior compared with that after mechanical valve replacement in a real-world setting [1]. This normal survival is unquestionably the best achievable surgical result and it is supported by other randomized prospective trials as well, altogether revealing a survival benefit for the Ross operation versus allografts or mechanical valves in the real-world setting [3, 4]. This is supported by considerable literature as well as by the data of the German– Dutch Ross registry with now 2180 patients and nearly 20 years of follow-up [5]. In addition to a normal survival, a perfect Ross offers the patient well into the second postoperative decade a life without any anticoagulation and all its side-effects, a life without lifestyle restriction, with the lowest risk of extracardiac sequelae like thromboembolism (macro and micro) and bleeding, without noise disturbance, with near physiological haemodynamics at rest and exercise as well as with growth potential. This is likely due to the fact that the Ross operation realizes the theoretical advantage of an autologous, physiological, living aortic valve substitute. Despite this growing evidence for favourable results, the application of the Ross operation seems to decline. The skepticism over the Ross operation usually focuses on three main arguments: the potentially increased operative mortality of the Ross procedure, the risk of reoperations as well as the complexity of the procedure itself and the lack of reproducibility. The operative mortality of the Ross operation published by Andreas et al. [1] and da Costa et al. [2] was comparable with that of conventional aortic valve replacement being 2.1% in the German Aortic Valve Registry [6]. Also in other centres the hospital mortality of the Ross operation is around 1% [7]. In our series of 629 subcoronary patients, we lost 2 patients early postoperatively [8], none in the last 400 cases. Thus, the argument of increased hospital mortality after the Ross procedure is not appropriate in general. The second main argument against the Ross operation is the risk of reoperation on two operated valves. This overall risk is low at about 1% per patient-year [5] in experienced centres at least up to 18 years postoperatively, and carries a low …