The Ross procedure is a highly specialized option for aortic valve replacement, with long-term durability and excellent outcomes in a wide range of adult patients with aortic valvular disease. These are the results of a new groundbreaking study led by Ismail El Hammamsy, MD, world-renowned Mount Sinai cardiac surgeon and chief of aortic surgery at the Mount Sinai Health System, and published June 23 in the journal Ismail El Hammamsy, MD. Journal of the American College of Cardiology (Jack).
This landmark publication represents the largest North American study ever conducted on the Ross procedure. The findings from this contemporary cohort establish a benchmark for the durability of this specialized surgery when performed by experienced surgeons using customized surgical techniques in a high-volume center of excellence. This study confirms the unique role of the Ross procedure in adults and further questions long-held notions about the procedure. The findings suggest that the Ross procedure should be considered for a broader group of appropriately selected patients, including adults over 50 years of age and patients with aortic regurgitation, who have traditionally been considered poor candidates.
The Ross procedure is the only aortic valve replacement procedure that has been consistently proven to restore life expectancy in the age- and sex-matched general population. This comprehensive longitudinal study highlights the unique advantages of the Ross procedure in adults, including superior valve durability and excellent long-term clinical outcomes. Importantly, our findings challenge long-held assumptions by demonstrating superior outcomes in a historically overlooked patient group. ”
Randall B. Griep, MD, Professor of Cardiovascular Surgery, Icahn School of Medicine, El Hamamsy, PhD
The Ross procedure involves replacing a patient’s diseased aortic valve with your own pulmonary valve. This closely reflects the structure and function of a healthy aortic valve. Unlike traditional aortic valve replacement, which uses tissue or mechanical valves, the Ross procedure provides a living autologous valve in place of the aorta. Through adaptation, the valve can reproduce the biological and hemodynamic properties of the native aortic valve. These unique properties contribute to improved long-term outcomes compared to biological and mechanical valves.
Mechanical valves are durable but require lifelong anticoagulation and associated lifestyle restrictions. Although bioprosthetic valves avoid anticoagulation, they often deteriorate over time, especially in younger patients. In both cases, the aortic valve is replaced with a nonliving replacement that does not have the ability to repair, adapt, or grow. In contrast, the Ross procedure provides a living pulmonary valve in the aortic location, resulting in physiological valve function, excellent durability, and a normal quality of life.
“The fundamental advantage of the Ross procedure is that it returns a living valve to the position of the aorta,” explains Dr. El Hammamsy. “This difference translates into unique long-term benefits for patients.”
Historically, the Ross procedure has been most commonly performed on adults younger than 50 without aortic regurgitation. Aortic regurgitation is a condition in which the aortic valve does not close properly, forcing blood to flow backwards from the aorta into the heart’s main pumping chamber (left ventricle), forcing it to work harder. In these patients, the Ross procedure has traditionally been associated with decreased durability of the pulmonary valve.
The study followed 455 adults who underwent Ross surgery between 2011 and 2019. All surgeries were performed by Dr. El Hamasy and his team. Patients participated in a dedicated follow-up program that included regular clinical evaluations and annual echocardiography. The mean age of the patients was 48 years. Half of the cohort was over 50 years old. 10% were over 60 years old, with the oldest patient being 67 years old.
Survival at 12 years after surgery was comparable to the general population. More than 96 percent of patients did not require cardiac reintervention, and more than 98 percent did not have significant aortic valve dysfunction. The rate of permanent pacemaker implantation required was less than 1%, significantly lower than the rate reported after traditional aortic valve replacement. No patients experienced patient-prosthesis mismatch (this occurs when the implanted heart valve is too small compared to the patient’s body size) and there were no cases of aortic valve endocarditis. Of 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 researchers also compared the outcomes of patients with aortic stenosis (a heart valve disease in which the aortic valve narrows, restricting blood flow from the heart to other parts of the body, making it harder for the heart to pump blood) and patients with aortic regurgitation. For the first time, no differences in aortic valve function or need for reintervention were observed at 12 years, paving the way for consideration of the Ross procedure in this patient population.
“These results demonstrate that using a tailored surgical approach for patients with aortic regurgitation can eliminate differences in long-term outcomes,” says Dr. El Hamasy.
His pioneering research has become the standard of care for Ross surgery at many centers around the world.
“Furthermore, our findings show similar results in patients older than 50 years, challenging the traditional paradigm of routine use of tissue or mechanical valves in this age group. The combination of superior durability, restored survival, and normal quality of life prompts new consideration of the Ross procedure in the elderly.”
While the results are promising, the researchers emphasize that outcomes after the Ross procedure are closely related to surgeon experience, institutional expertise, and professional postoperative management.
“These achievements reflect the efforts of a dedicated interdisciplinary team and a mature Ross program,” said Dr. El Hammamsy. “The Ross procedure is a technically demanding procedure and should be performed in an experienced, high-volume center that is committed to comprehensive patient care and close follow-up.”
Dr. El Hammamsy, director of the Adams Oral Institute at 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 Roth programs in 15 countries.
As interest in the Ross procedure continues to grow around the world, researchers are also pursuing advances in tissue-engineered heart valves that have the potential to further expand treatment options for patients with aortic valvular disease and advance cardiovascular care.
sauce:
Mount Sinai Health System
Reference magazines:
El Hamamsy, I. Others. (2026). Modern outcomes of Ross surgery in adults. Journal of the American College of Cardiology (Jack). DOI: 10.1016/j.jacc.2026.03.173. https://www.jacc.org/doi/10.1016/j.jacc.2026.03.173
