Building a de novo pediatric Ross program: Learning curve, case concentration, and the role of intraoperative guidance

Objective Data are limited regarding the building of a de novo pediatric Ross program. We aimed to characterize the programmatic learning curve of a new Ross program and evaluated the association between case concentration, intraoperative guidance, and technical quality. Methods We retrospectively reviewed 70 consecutive Ross procedures in our center between May 2018 and December 2025. Surgical performance was assessed by operative efficiency (aortic cross-clamp time), intraoperative technical quality (Residual Lesion Score [RLS]), and composite safety outcomes. Outcomes were compared between cases performed by the lead Ross surgeon (n=47) and lower-volume surgeons (8 surgeons, n=23). Lower-volume surgeons were further categorized as lead surgeon-guided (n=9) or independent (n=14). Learning curves were assessed using cumulative sum (CUSUM) analysis. Results The median age at Ross procedure was 8.8 years (IQR, 5.6-12.6 years). Hospital mortality was 1% (n=1). The lead Ross surgeon achieved early efficiency and a sustained downward safety CUSUM trajectory, with an RLS-1 (ideal repair) rate of 79%. Lower-volume surgeons exhibited a persistent upward risk-adjusted CUSUM trajectory indicating prolonged cross-clamp time and clustered safety events without reaching an efficiency plateau. Among lower-volume surgeons, lead surgeon-guided cases had shorter operative times, higher RLS-1 rates (89% vs 57%) and no suboptimal RLS-3 repairs (0% vs 21%) compared to those operating independently. Conclusions Development of a de novo pediatric Ross program requires deliberate strategies for expertise acquisition. Concentrated case exposure and intraoperative guidance may facilitate acquisition of technical consistency during early Ross program development.