Ross procedure at the crossroads.

The quest for a perfect heart valve substitute has been going on for half a century. In 1960, Lower et al1 described the feasibility of replacing the aortic valve of dogs with the native pulmonary valve. In 1967, Ross performed this procedure in humans.2 Ross transferred the pulmonary valve into the aortic root with the same technique used to implant aortic valve homograft3 (ie, the pulmonary sinuses of the pulmonary root were partially excised, and the pulmonary valve was secured in the recipient’s aortic root with 2 suture lines, 1 below and 1 above the aortic annulus, leaving the coronary artery orifices unobstructed). Although many surgeons gained experience with this type of aortic valve replacement using an aortic valve homograft, the Ross procedure did not gain widespread popularity until the late 1980s when the technique of aortic root replacement was described for this operation.4 In this approach, the aortic root is excised, the pulmonary root is sutured to the aortic annulus and ascending aorta, and the coronary arteries are reimplanted into the neoaortic root. This technique made the early outcomes more predictable than when the subcoronary technique was used, and enthusiasm for the Ross procedure increased during the 1990s. A voluntary international registry was developed, and thousands of patients were entered into that registry,5 but there have been no reports on long-term results. In the year 2000, we reported that the pulmonary autograft dilated and that the dilation was often accompanied by aortic insufficiency (AI) when the pulmonary autograft was used as a freestanding neoaortic root, whereas the techniques of subcoronary implantation and aortic root inclusion (pulmonary root inside of the aortic root) prevented dilation during a mean follow-up of 44 months.6 Other investigators confirmed our findings of dilation of the pulmonary autograft and AI after the technique of aortic root replacement.7,8 As the fallibility of the Ross procedure became apparent, fewer surgeons continued to perform it. Among those, Sievers et al9 demonstrated excellent valve function and lack of dilation of the aortic root after the Ross procedure using the subcoronary technique exclusively, but their mean follow-up was only 3.9 years. Article p 222