Rupture and dissection of aortic autograft following the ross procedure: a systematic review

The Ross procedure offers physiologic hemodynamics and freedom from anticoagulation for young patients needing aortic valve replacement, yet rare catastrophic complications such as autograft (neoaortic) dissection and rupture can occur years later. PRISMA-guided search (inception–August 2025) identified peer-reviewed reports with patient-level data on presentation, imaging, management, and outcomes. Eleven cases were included. Median age was 39 years (range 20–56) and 55% were male. Median interval from Ross to event was 10 years (range 6–18). Native bicuspid aortic valve (BAV) morphology was documented in 9 out of 11. Median autograft root diameter was 55 mm (range 50–90), with 60% occurring at ≤ 55 mm. Presentations were symptomatic in 7/11, incidental in 3/11, and fatal preoperative rupture in 1/11. Echocardiography was the most common initial test; diagnosis was confirmed by CT (6/11) or MRI (3/11). Disease was confined to the autograft root in 9/11. Ten patients underwent operative intervention with 100% survival to discharge (composite root replacement 6/10; valve-sparing or root remodeling 4/10). Autograft dissection or rupture after Ross is rare but life-threatening, concentrated among patients with native BAV, and can occur below conventional diameter thresholds. Vigilant lifelong surveillance and consideration of earlier elective intervention are warranted.