North American Trends in Utilization and Outcomes of the Ross Procedure: A Word of Caution

We sought to evaluate contemporary trends in utilization of the Ross procedure in adults and investigate the relationship between surgical volumes and in-hospital mortality. The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients who underwent the Ross procedure. We used mixed-effects logistic regression to investigate the relationship between Ross volumes and in-hospital mortality. Statistical significance was evaluated using likelihood ratio tests. Between 2008 and 2023, 2,268 Ross procedures were reported. Median age was 43 years (IQR: 32–52), and 1,550 (68%) patients were male. Utilization of the Ross procedure reached a nadir in 2017 (n = 63) before increasing annually, reaching 531 cases in 2023. In 2017, Ross procedures represented 0.9% of all AVRs performed on patients aged ≤60 years; by 2023, this proportion had increased to 7.2%. The risk of in-hospital mortality associated with the Ross procedure declined from 2.8% in 2008 to a nadir of 0.9% in 2020 before increasing to 1.9% in 2023. Compared with centers that performed more than 10 Ross procedures annually, in-hospital mortality was higher in centers that performed only 1 or 2 Ross operations per year (OR 4.5 [95% CI: 1.5–13.2]; p=0.006). Utilization of the Ross procedure is increasing in North America. There is a clear inverse relationship between the volume of Ross procedures and early surgical outcomes. The operative mortality of the Ross procedure is unacceptably high when performed in low-volume centers. The Ross procedure should only be performed in high-volume comprehensive valve centers of excellence.