Autograft homecoming: Midterm outcomes and pulmonary valve function after Ross reversal

OBJECTIVE Autograft failure and risk of losing a second native valve are important drawbacks of the Ross procedure. Ross reversal, pioneered in 2006, involves repairing and returning the autograft to its original pulmonary position. We report midterm outcomes of the Ross reversal procedure focusing on function of the returned pulmonary valve. METHODS From 1/2006-1/2024, 52 adults, mean age 49±14 years, underwent Ross reversal for autograft failure at Cleveland Clinic. Clinical outcomes included operative mortality and major morbidity, reintervention, and survival. Echocardiographic outcomes included pulmonary regurgitation grade and pulmonary valve gradients. Median follow-up for clinical and echocardiographic data was 8.0 and 1.7 years, respectively. Data were analyzed using the Kaplan-Meier method and multiphase nonlinear mixed-effects regression modeling. RESULTS Primary indications for Ross reversal were moderate or greater autograft regurgitation (n=47; 90%) and neo-aortic root aneurysm (n=39; 75%). The autograft was replaced with a mechanical valve in 32 (62%), bioprosthetic valve in 15 (29%), and allograft in 5 (10%). There were no in-hospital deaths, 1 non-disabling stroke (2%), 1 acute kidney injury requiring dialysis (2%), and 3 prolonged intubations (6%). At 10 years, probability of no or mild pulmonary regurgitation was 80% and of moderate pulmonary regurgitation 20%; peak and mean pulmonary valve gradients were 12 and 6 mmHg, respectively. No patient developed infective endocarditis. One well-functioning returned pulmonary valve was damaged and replaced during a subsequent aortic root reoperation. CONCLUSIONS Ross reversal is an effective solution for autograft failure, with stable function of the returned pulmonary valve out to 10 years.