Establishing a Ross Program: Early Experience and Outcomes of the First 50 Cases Compared to Propensity-Matched Aortic Valve Replacements

Background The Ross procedure (RP) is technically complex but offers superior hemodynamics and improved long-term survival compared to prosthetic aortic valve replacement, particularly in young adults. Despite these advantages, widespread adoption has been limited by concerns regarding technical complexity, operative risk, and the learning curve associated with Ross program development. This study evaluates the early experience of the first 50 RPs performed by a lead surgeon compared to propensity-matched surgical aortic valve replacement (SAVR). Methods The RP has historically been criticized for its higher operative complexity and perceived risk during the learning curve. To address this, we compared the first 50 RPs performed by a lead surgeon within a structured Ross program to 50 propensity-matched isolated SAVR patients. The primary outcome was 30-day mortality, while secondary outcomes included perioperative events, operative times, and valve hemodynamics. Results The Ross cohort was younger (42 vs 53 years, P < .01) and had lower rates of hypertension (40.0% vs 62.1%, P = .005). Twenty six cases (52%) were performed with structured two-attending mentorship. After propensity matching, no 30-day mortality was observed in either group. Ross procedures had longer cross-clamp times (183 [161-211] vs 83 [66-103] min, P < .01) but achieved lower mean aortic valve gradients (4 [3-4] vs 9 [7-12] mm Hg, P < .01) with similar lengths of stay (6 [5-7] days vs 6 [5-7] days, P = .81). Although several important perioperative technical events occurred during the Ross experience, including unplanned coronary bypass grafting and reoperation for autograft dysfunction, these events were recognized promptly and managed successfully without excess mortality or major morbidity. Conclusions Our early experience suggests that establishment of a modern Ross program is feasible with excellent early outcomes when supported by careful patient selection, structured mentorship, operative standardization, multimodality imaging, and robust institutional infrastructure. Importantly, transparent reporting of technical complications, lessons learned, and evolving perioperative strategies during the learning curve may help guide safe dissemination of the Ross procedure to additional centers.