Ross Procedure Renaissance: A Contemporary Review of Patient Selection, Technique, and Long‐Term Outcomes in Adults

Abstract

Renewed interest in the Ross procedure, driven by compelling evidence of superior long‐term outcomes, has led to increased international use. This review outlines a comprehensive framework for understanding the Ross procedure within the broader context of aortic valve replacement. Topics include procedural overview, patient selection and contraindications, diagnostic imaging, technical modifications to promote durability, clinical outcomes, postoperative management, and future directions. The Ross procedure remains the only valve replacement strategy capable of restoring life expectancy in selected young and middle‐aged adults, making it an imperative option for multidisciplinary consideration.

Nonstandard Abbreviations and Acronyms

AVR

aortic valve replacement

PPM

patient–prosthesis mismatch

RP

Ross procedure

TTE

transthoracic echocardiography

First introduced by Donald Ross in 1967, the Ross procedure (RP) has seen fluctuating adoption over the past several decades. After initial enthusiasm, its use declined in the early 2000s due to concerns about technical complexity and autograft durability. ¹ However, compelling evidence of excellent long‐term outcomes, such as restored life expectancy, superior hemodynamics, and lower rates of reintervention, has fueled a resurgence in its use, often referred to as the “Ross Renaissance.2, 3, 4, 5 In the United States in 2023, the RP accounted for 7% of all aortic valve replacements (AVRs) in patients aged <65 years. Prosthetic heart valves (tissue or mechanical) have consistently been associated with high rates of patient–prosthesis mismatch (PPM), ⁶ , ⁷ a reduction in life expectancy, ⁸ , ⁹ and the need for reintervention or anticoagulation.

Prosthetic valves can fail because of stenosis, regurgitation, or infection. Mechanical prosthetic valves are often considered “lifetime valves,” but a subset of patients develop stenosis secondary to pannus, thrombus, or both. The estimated failure rate of a mechanical valve is 0.5% per year. ¹⁰ , ¹¹ Complications associated with anticoagulation are not trivial, with rates of major bleeding or thrombosis averaging 1% per year. Structural valve degeneration of bioprosthetic leaflets secondary to calcification or increased stiffness may result in isolated stenosis. Regurgitation of bioprosthetic valves is often acute or subacute secondary to tearing of ≥1 leaflets and may result in clinical heart failure (Figure 1). Figure 2 demonstrates echocardiographic images of failed prosthetic valves.

Figure 1. Failed prosthetic valves.

Examples of prosthetic valve failures by stenosis, regurgitation or both. Top row: example of mechanical valves. Bottom row: example of bioprosthetic valves.

Figure 2. Echocardiographic images of failed prosthetic valves.

A, Transesophageal echocardiogram showing prolapse of 2 bioprosthetic valve leaflets (arrows) with severe transvalvular regurgitation. B, Echocardiogram and noncontrast computed tomography demonstrating limited leaflet mobility in a bileaflet mechanical aortic valve with severe aortic stenosis. C, Echocardiogram showing severe aortic stenosis with a mean gradient >50 mm Hg; computed tomography angiography revealed minimal leaflet calcification. D, Echocardiogram revealing combined severe stenosis and moderate regurgitation in a bioprosthetic aortic valve; the leaflets were thickened and immobile without calcification, and perforations were noted.

When performed by experienced high‐volume surgeons on carefully selected patients, the RP is uniquely capable of restoring normal life expectancy for individuals requiring aortic valve replacement. ⁴ , ¹² , ¹³ , ¹⁴ Moreover, the durability of the RP is markedly better than that of a bioprosthesis and not significantly different than a mechanical valve. ¹⁵ , ¹⁶ As cardiologists are at the cornerstone of managing patients with aortic valve disease, knowledge about this procedure and appropriate patient selection and education is necessary in the modern era. This review aims to concisely address the key questions every cardiologist should be equipped to answer when discussing options for aortic valve intervention, including the RP, with prospective patients.

Historical Context and Surgical Overview

The RP is an operation to replace a dysfunctional aortic valve that involves transplanting the native pulmonary valve into the aortic position (autograft) and reconstructing the right ventricular outflow tract (RVOT) with a donated human allograft (homograft) (Figure 3). ¹⁷

Figure 3. Proposal of algorithm for post–Ross procedure management.

PPI indicates proton pump inhibitor; SBP, systolic blood pressure; and TTE, transthoracic echocardiograhy.

Since the native pulmonary valve functions in the low‐pressure environment of the RVOT, it is typically free from the degenerative pathology seen in the higher‐pressure aortic position. The RP was first described by Donald Ross in 1967 in London and has seen variable degrees of use in both children and adults since that time. ¹⁸ Due to the increasing evidence demonstrating improved long‐term outcomes of the RP compared with prosthetic heart valve replacement, the demand for the RP has been rising. In 2023, the RP accounted for 7% of all AVRs in patients aged <65 years in the United States. With the increasing use, preserving excellent outcomes is of paramount importance. To achieve this, patients must be carefully selected and operated on at high‐volume RP centers of excellence. ³ , ⁹ , ¹⁹

Patient Selection and Contraindications

The RP should be considered for any patient in need of AVR who may benefit from the enhanced hemodynamics, durability, and life expectancy. While there is no strict upper age limit, the RP is typically considered for younger patients. However, there are specific clinical scenarios that make the RP more favorable for older adults. A variety of clinical factors must be weighed in considering risks and benefits of the RP compared with alternative approaches, and there are certain patient populations that might be considered ideal (Table 1). For example, in a 34‐year‐old patient with congenital aortic stenosis, the RP offers better long‐term survival compared with both mechanical and bioprosthetic AVR. ¹⁵ In a 59‐year‐old patient with a large aortic annulus, the optimal approach is less well defined. The RP may be reasonable for selected patients seeking to avoid anticoagulation and optimize hemodynamics, especially in the setting of PPM. However, a large tissue or mechanical prosthesis may be preferable in those with shorter life expectancy or higher operative risk. Available data are limited in the assessment of equipoise in this scenario.

Table 1.

Indications/Contraindications for the Ross Procedure

Ideal	Consider	Contraindication
Aged <65 y with normal life expectancy who need AVR from aortic stenosis or aortic regurgitation Women of childbearing potential who desire future pregnancy Without significant pulmonary valve pathology High potential for good long‐term survival	Aged ≥65 y with normal life expectancy depending on individual risk–benefit analysis Discordance between body surface area and aortic annular diameter Aortic endocarditis who requires surgical intervention Reoperations requiring AVR Single‐vessel coronary artery disease Concomitant repairable valvular heart disease Preference to avoid anticoagulation Preference to avoid animal tissue for religious or other reasons	Significant comorbidities/limited life expectancy Connective tissue disorders Uncontrolled hypertension not amenable to preoperative control Multivessel coronary artery disease or nonrepairable concomitant valvular heart disease Risk of tolerating long operations Low left or right ventricular function or renal dysfunction Presenting in shock or severe extremis Dysfunctional pulmonary valve*

AVR indicates aortic valve replacement.

^*True absolute contraindication.

As a general guideline, the following patient populations are appropriate to consider for the RP:

1. Patients aged <65 years with normal predicted life expectancy who need AVR

The operation can be used for patients who need AVR for aortic stenosis or regurgitation. Certain patient populations require technical modifications to ensure durability, which will be discussed later.

• 2Patients with discordance between body surface area and aortic annular diameter

Residual or persistent aortic stenosis after AVR (PPM) is a major problem that affects about one third of both transcatheter and surgical AVRs. ⁶ , ²⁰ , ²¹ PPM results in the need for early intervention and is associated with a marked reduction in life expectancy. ⁷ , ²² , ²³ The RP is unique because the autograft is size matched to the patient’s body surface area in most patients. This results in low (single‐digit) gradients across the valve that remain stably low for decades. ¹² , ²⁴ , ²⁵ , ²⁶ , ²⁷ Failure by stenosis is almost unheard of. All other options for AVR can fail by stenosis (leaflet degeneration in bioprosthetic valves and pannus or thrombosis in mechanical valves) with resultant well‐established deleterious effects on the left ventricle and life expectancy. In patients whose body surface area necessitates a larger valve than the annulus will allow, surgeons must consider strategies to avoid PPM. Options for this include aortic annular enlargement, root replacement with a stentless valve or homograft, and the RP. While aortic annular enlargement techniques have been recently popularized and are increasing in use, there are no long‐term outcome studies to confirm their efficacy with respect to durability or life expectancy.

• 3Women of childbearing age

In women of childbearing age who need AVR, the decision about choice of prosthesis is particularly challenging. Therapeutic anticoagulation during pregnancy confers significant increased risk to both mother and fetus, ²⁸ and left‐sided bioprosthetic valves confer higher risk of cardiovascular complications in pregnancy compared with right‐sided prostheses. ²⁹ The RP offers excellent outcomes in limited series given the lack of left heart obstruction and lack of need for anticoagulation ³⁰ and should be considered for women planning future pregnancy where appropriate.

• 4Patients with infectious endocarditis

Infective endocarditis often affects the aortic valve and root, necessitating surgical intervention. The RP can be the ideal option in patients with normal life expectancy. Rates of autograft endocarditis after the RP are exceedingly low. ⁴ , ¹² , ³¹ Because the RP involves tissue‐to‐tissue connections, hemostasis in the setting of endocarditis is much easier to achieve than tissue‐to‐Dacron. Particularly in situations where a homograft aortic root replacement is being contemplated, the RP has clearly been shown to be superior. ³² Surgeons must balance the risk of a longer, more complex operation with patient factors when considering the RP in this scenario.

• 5Reoperative patients

Patients who have had failed aortic valve repair or surgical AVR in the past and now need re‐replacement due to structural valve degeneration, paravalvular leak, pseudoaneurysm, or endocarditis should be considered, as the RP may restore normal long‐term survival without the need for long‐term anticoagulation compared with redo prostheses.

In general, the patient populations who should not be considered for the RP are those with significant comorbidities/limited predicted life expectancy, concern for durability, or prohibitive surgical risk:

1. Comorbidities/Limited life expectancy

It is important to evaluate patient comorbidities and understand family history to estimate life expectancy when considering the RP. It is the general understanding that patients should have an estimated life expectancy of at least 20 years before considering the RP. Patients with concomitant coronary artery disease in a single vessel may be considered, but the RP is not favorable with multivessel coronary disease. Patients with concomitant mitral or tricuspid valvular disease may also be considered but only if the valve is repairable. If a prosthetic heart valve is used in another position, the RP is not a favorable option.

• 2Concern for durability:

Patients with connective tissue disorders (Marfan syndrome, Loeys–Dietz syndrome, vascular Ehlers–Danlos syndrome) are currently not considered candidates due to concern for durability. There is interest in evaluating the RP in these patients using inclusion techniques to stabilize the autograft, but at present there are no data to support these practices. Patients with native pulmonary valve disease may be excluded depending on the specific issues. In general, a central mild pulmonary regurgitation is tolerated for autograft replacement; however, eccentric or commissural regurgitation may be due to prolapse or fenestrations and must be carefully evaluated intraoperatively before use of the autograft. Patients with uncontrolled hypertension should not be considered for the RP unless they can be well controlled preoperatively. Lifelong careful blood pressure control following the RP is imperative to preserve autograft function and reduce the risk of autograft regurgitation. ⁴ , ¹²

• 3Prohibitive surgical risk:

Patients at increased risk of tolerating longer operations may not be appropriate candidates for the RP. These include those with reduced left or right ventricular systolic function or renal dysfunction. Patients who present in shock or extremis are generally not considered for the RP for 2 reasons. First, operative duration for the RP is longer than surgical AVR, and critically ill patients typically benefit from shorter operative duration. Second, there often is not time in the context of acute decompensated disease to adequately educate a patient about the procedure and thus expect informed consent.

Diagnostic Evaluation and Preoperative Imaging

Patients should be evaluated in the office with a comprehensive history and physical examination. The history taking should include questions to both understand patient compliance and estimate life expectancy. The physical examination should include blood pressure recordings in both arms and an upper‐ and lower‐extremity pulse examination, as well as evaluation for signs of genetic aortopathy. All patients being considered for the RP should have a transthoracic echocardiogram (TTE) and an ECG‐gated coronary computed tomography angiography with imaging of the thoracic aorta. These 2 studies are adequate in most young patients. Some centers may use transesophageal echocardiography, invasive coronary imaging, or cardiac magnetic resonance imaging when appropriate.

TTE imaging of the pulmonary valve is challenging and requires assessment in multiple views with and without color Doppler. The parasternal short‐axis view at the level of the aortic valve is typically best for leaflet visualization. It is important to rule out leaflet prolapse, confirm the presence of a trileaflet pulmonary valve, and evaluate for aortic coarctation. The parasternal long‐axis view with focus on the RVOT is optimal for visualization of the small central leak typically present in the pulmonary valve. The subcostal view of the RVOT may be useful in some patients, particularly to exclude RVOT obstruction at other levels (subvalvular, supravalvular). Transesophageal echocardiography may be useful for native pulmonary valve assessment in patients with suboptimal TTE views but is often not necessary.

In our experience, low‐radiation protocol coronary computed tomography angiography can clearly delineate normal coronary branching anatomy, as there are coronary anomalies that would make the RP contraindicated. This can also be assessed by cardiac magnetic resonance imaging. ECG gating for computed tomography angiography allows for multiplanar reconstruction and accurate measurement of the aortic and pulmonary annuli, which are of paramount importance to preoperative planning. Size discrepancies between the annular sizes can be dealt with intraoperatively, but it is best to know this before the operation, as it may decrease the probability of proceeding with the RP.

Operative Technique and Technical Refinements

The RP is technically a heavily nuanced operation that mandates great attention to symmetry and precision. Certain patient populations necessitate a bespoke approach to ensure durability. These typically include patients with bicuspid aortic valve, dilated aortic annuli, primary aortic regurgitation, and ascending aortic aneurysms.

Since its inception, each step of the operation has been modified and optimized to promote durability. This starts with autograft harvest where only a small segment of the pulmonary artery and right ventricle are cut to ensure the autograft conduit is as short as possible. The autograft is then implanted deep in the left ventricular outflow tract, so the pulmonary annulus is externally supported by the native aortic annulus. External annuloplasty is performed for stabilization in patients with risk factors for aortic annular dilation or with aortic/pulmonary annular size mismatch. All excess pulmonary artery tissue is then removed and the sinotubular junction is stabilized with a short interposition graft. Stabilizing both ends of the autograft prevents the neo‐aortic valve from developing regurgitation. Some Ross surgeons routinely perform a full inclusion technique where the autograft is sewn into a Dacron graft before implantation. While this practice may be appropriate for patients at extreme risk of sinus dilation, it may negate some of the benefits of the RP, and thus we do not practice this technique. Most RP experts prefer the use of acellular pulmonary homografts that, when possible, are sex‐matched and oversized. All excess pulmonary artery, muscle, and fat are carefully removed from the homograft before implantation, as this may contribute to early homograft failure.

For more detailed operative guidance, we refer the reader to Mazine et al ¹⁷ and Williams et al, ³³ which offer comprehensive step‐by‐step technical descriptions of the operation.

Outcomes: Survival, Reoperation, and Valve‐Related Complications

A donated human allograft (homograft) is a conduit that can be used in the aortic position in some infrequent situations such as endocarditis with significant tissue destruction. However, many studies have demonstrated similar durability compared with bioprosthetic heart valves, with the added complexity of reoperation on a calcified homograft. ⁵ , ¹⁴ , ³⁴ , ³⁵ These homografts are nonliving tissue made of collagen extracellular matrix, unlike the autograft in the RP, which is composed of living tissue. This is thought to be one of the primary reasons for the improved durability of the RP compared with homograft root replacement. The authors prefer to use an acellular cryopreserved pulmonary homograft for the RP, which, in addition to numerous technical modifications, leads to less inflammation and improved durability.

The potential short‐term complications after the RP are similar to those of other aortic valve or root procedures if performed at high‐volume centers. Numerous studies have shown that these risks are comparable to those experienced by patients undergoing AVR. ⁸ , ¹² , ¹⁴ However, these studies must be interpreted carefully, as the RP is typically offered to healthy, low‐risk patients. We inform patients that the RP is a longer operation involving full‐root replacement and is qualitatively riskier than AVR. This up‐front risk is mitigated in high‐volume Ross centers, where the RP is performed with equivalent risk to AVR. ¹ , ³ , ⁵ , ³⁶ The authors believe that, to offer the RP to low‐risk patients, it is imperative the expected mortality risk must be <1%. Patients should understand that they will undergo a longer, more technically nuanced operation for the potential of a greater long‐term outcome.

The long‐term outcomes after RP are excellent and have repeatedly been shown to be superior to bioprosthetic and mechanical AVR ⁴ , ⁹ , ¹⁴ , ³⁶ (Table 2). The most significant of these outcomes is the restoration of a normal life expectancy, matched by sex and age, which has been demonstrated by many studies from various countries. ¹⁴ , ¹⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² Furthermore, the durability and freedom from reoperation with RP significantly exceed those of a bioprosthetic valve and are not significantly worse than those of a mechanical valve. ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ Study‐level characteristics and specific follow‐up durations are detailed in Table S1.

Table 2.

Survival, Freedom From Reoperation, and Bleeding Outcomes^*

Outcome	Ross procedure	Bioprosthetic valves	Mechanical valves	Transcatheter aortic valve†	Aortic valve repair
Survival, %	89–97 4 , 9 , 12 , 14 , 59 , 60 Comparable to general population	60–88 8 , 9 , 61 , 62 Reduced compared with Ross procedure	62–88 4 , 9 Similar rates to bioprosthetic valves	≈20 63 , * 10‐y follow up; limited data are available beyond 10 y	81–87 64 , 65 , 66 Comparable or superior to bioprosthetic and mechanical valves
Freedom from reoperation, %	84–92 4 , 14 , 41 , 59 Lower rates compared with bioprosthetic valves	55–70 62 , 67 , 68 , 69 Higher rates of reintervention due to structural degeneration 39	85–94 14 , 69 Lower rates compared with bioprosthetic valves	50–60 70 * Higher rates of reintervention due to structural degeneration	83–95 64 , 66 , 71 Lower rates compared with bioprosthetic valves
Bleeding, %	1.9 9 Minimal risk, comparable to native valve	3.3–6.6 9 , 14 Lower risk compared with mechanical valves	5.2–13 8 , 9 High risk due to mandatory anticoagulation; bleeding rate for On‐X valve <1.0%/patient‐year 72	Data on long‐term bleeding rates are limited for transcatheter AVR given recency of adoption	<1*, 73 Exceedingly low risk of bleeding

AVR indicates aortic valve replacement.

^*All outcomes represent Kaplan–Meier estimates at the longest available follow‐up (typically 10–25 y) unless otherwise specified. See Table S1 for study‐level characteristics and follow‐up durations.

^† TAVR data limited to 10‐y follow‐up from early cohorts of high‐risk older patients.

Postoperative Management and Surveillance

Patient management after the RP aims to mitigate inflammation, promote durability by minimizing afterload, and monitor valvular function (Figure 3). Some high‐volume operators use NSAIDs such as naproxen for the first 6 months to mitigate inflammation to the homograft. To reduce the risk of gastrointestinal complications, a proton pump inhibitor can be used concomitantly.

The single most important factor to promote durability after the RP is strict lifelong blood pressure management, which cannot be overemphasized. Patients are asked to check their blood pressure twice daily and may need serial titration of antihypertensive medications in the early postoperative period. We target a systolic blood pressure goal of <110 mm Hg for the first 6 months postoperatively. First‐line pharmacotherapy includes a β blocker followed by an angiotensin‐converting enzyme or angiotensin receptor blocker. After 6 months, therapy is tailored to the patient with the underlying principle that the lower the blood pressure, the more durable the operative repair will be. The blood pressure monitoring and management is critical and requires coordination between the surgical and cardiology teams.

All patients undergo a TTE before discharge, as the conformation and function of the valve can change in the first 72 hours. Patients are seen 4 to 6 weeks after surgery with a chest radiograph and renal function analysis to ensure the NSAID is safe to continue. Repeat TTE is performed at 6 months and every 1 to 2 years for life to ensure adequate function and early detection of issues. Notably, the 2020 American College of Cardiology/American Heart Association Guidelines for the Management of Patients With Valvular Heart Disease recommend baseline imaging, follow‐up at 5 and 10 years, and then annual imaging for standard bioprosthetic valves. ⁴⁸ However, more frequent monitoring is appropriate for the RP due to its unique dual‐valve nature, with both an autograft in the systemic circulation and a homograft in the pulmonary position. Ideally, this closer surveillance enables early detection of potential issues with either valve and allows for timely intervention if needed. The competency and flow dynamics of both valves are meticulously tracked in a Ross quality monitoring program. Follow‐up computed tomography angiography may also be considered to monitor for ascending aortic dilation, particularly among patients with bicuspid aortic valves, as these patients often need to be followed for progression of aortic dilation.

Quality of life after the RP is typically excellent, as the patient has normal hemodynamics with no outflow limitation and potential freedom from all medication after the first year following surgery. ⁴ Given the specialized nature of dual valve assessment in patients undergoing the RP, we recommend a collaborative approach that includes adult congenital heart disease specialists in the follow‐up care team. Adult congenital heart disease specialists bring complementary expertise in pulmonary valve assessment and RVOT evaluation, which can enhance the comprehensive monitoring of both the autograft and homograft components.

Durability and Reintervention Strategies

Reintervention after the RP occurs at a rate of <1% per year. ¹² , ²⁴ , ⁴¹ , ⁴⁴ , ⁴⁹ Since that risk is cumulative, young patients are at higher risk of needed reintervention. The most recent study with the longest median follow‐up time showed that at 25 years after the RP, freedom from autograft intervention was 80% and homograft intervention was 86%. Importantly, the 30‐day mortality rate after the first Ross‐related reintervention was 0%. That study was a post hoc analysis of the only randomized clinical trial involving the RP. ³² It is critical that such reinterventions be performed by experienced RP surgeons, who are uniquely equipped to navigate the complex anatomic considerations and technical challenges of these reoperations.

Reintervention options after the RP vary depending on the specific issue:

1. Homograft stenosis

In most cases, the first line therapy for homograft stenosis has become transcatheter pulmonary valve replacement. This approach has revolutionized care for patients with pulmonary stenosis and avoids the need for repeat open surgery. ⁵⁰ , ⁵¹ However, there may still be scenarios that warrant surgical intervention such as early failure, infection, or anatomic contraindication to the transcatheter approach.

• 2Autograft regurgitation

In patients with severe autograft regurgitation after the RP who warrant therapy (symptoms or left ventricular dilation/dysfunction), reoperation is necessary. These reoperations can be done safely with low risk and should be performed by aortic surgeons with extensive root experience and, ideally, those who perform the RP. Transcatheter therapies such as the JenaValve are on the horizon for the treatment of aortic regurgitation and are being used in Europe. ⁵² , ⁵³ , ⁵⁴

• 3Autograft dilation

Since the autograft is the pulmonary root, it can dilate under systemic pressure. As discussed earlier, blood pressure control is of paramount importance to prevent this dilation. Some of the other strategies discussed, including using a short conduit and stabilizing the sinotubular junction, have resulted in a significant reduction in autograft dilation. ³⁶ , ⁴¹ Patients with aneurysmal autografts are typically managed similarly to those with aortic dilation albeit with different size thresholds for intervention. Typically, dilated autografts do not require intervention if <6 cm in diameter. While there are no data to guide this intervention threshold, neo‐aortic dissection or rupture is profoundly uncommon, with only a few cases reported. ⁵⁵ When intervention is required, options include valve‐sparing root replacement if the pulmonary valve remains competent or composite root replacement with a prosthetic valve.

Expanding Access and Future Directions

As the use of the RP continues to grow, further refinement and advancement of surgical techniques aimed at simplification and durability are necessary. One of the greatest challenges of this operation is its complexity, which can make safe dissemination difficult. The authors believe that the RP can be reproducibly taught to surgeons with extensive aortic root experience. Surgeons performing the RP at high volumes should be encouraged to educate other surgeons and trainees. It is essential to promote research and encourage industry to continue improving valve preservation and tissue engineering to enhance homograft durability. Minimally invasive approaches to aortic root surgery are slowly emerging and may be applied to the RP in the future. Transcatheter options for a regurgitant aortic valve could offer a useful alternative to reoperation for patients with autograft dysfunction. As the popularity of the RP grows, maintaining rigorous patient selection criteria and striving for excellent clinical outcomes is crucial to ensure the procedure’s long‐term viability. Advancing the field also requires improving national registries, conducting more robust prospective studies, and strongly considering randomized clinical trials to further substantiate and expand the evidence base.

Conclusions

In conclusion, the RP has proven to be a durable and effective option for AVR, particularly in carefully selected patients performed by experienced surgeons at high‐volume centers. The RP is the only AVR option with the potential to restore normal life expectancy. The resurgence of interest in the RP, or the Ross Renaissance, is timely, especially considering the growing use of transcatheter therapies for younger, low‐risk patients and the increasing recognition of the adverse effects of residual stenosis and PPM.

While mechanical heart valves are often touted for their longevity, there is limited evidence to support the claim of their indefinite durability despite their clearly lower rates of reintervention in comparison with bioprosthetic valves, ⁵⁶ , ⁵⁷ and they have been shown to negatively impact life expectancy, with increased rates of bleeding ⁵⁸ due to anticoagulation later in life. ⁸ , ⁹

Patient selection for the RP should be done in a multidisciplinary setting, involving close collaboration between cardiologists and surgeons. For those seeking qualified surgeons and centers of excellence, a useful starting point is the following website: https://therossprocedure.org/ross‐procedure‐surgeons. Given the technical complexity of the RP and the fact that it involves 2 valves, it is imperative that the procedure be performed by experienced surgeons at high‐volume centers to ensure optimal outcomes and minimize the risk of failure at both valve sites.

Finally, enhancing awareness through targeted education and dissemination of clinical outcome data is crucial to ensure that eligible patients are informed about this viable surgical option. By fostering a deeper understanding of the RP’s benefits and risks, we can empower clinicians to make more informed decisions and patients to actively participate in their treatment planning, ultimately leading to improved long‐term outcomes and quality of life.

Sources of Funding

None.

Disclosures

None.

Supporting information

Table S1