The Ross operation in children–what is the long-term fate of the autograft?

OBJECTIVES: The Ross operation achieves excellent outcomes in children and adolescents, but the influence of age at surgery and underlying pathology on long-term results remains uncertain. Evidence on autograft dilatation necessitating reintervention is also limited. This study aimed to identify patient groups best served from the Ross procedure and to evaluate long-term autograft performance. METHODS: All consecutive patients <18 years undergoing a Ross or Ross-Konno procedure between 1991-2024 at a single centre were analysed. Demographic, operative, and follow-up data were collected. Patients were stratified into age groups (neonate, infant, child, adolescent) and diagnostic groups (isolated aortic valve disease, aortic stenosis with subaortic stenosis, Shone's complex, and complex congenital heart disease [CHD]). Outcomes included overall survival, freedom from autograft and right ventricle-pulmonary artery (RV-PA) conduit reintervention, and severe autograft dilatation (>50 mm or > 25 mm/m2). RESULTS: A total of 226 patients underwent surgery at a median age of 8.5 years; 67% were male. Median follow-up was 9.5 years(IQR 12.7). Operative mortality was 2% and overall mortality 5%. Survival exceeded 90% at 30 years in all groups except neonates (60% at 5 years). After adjustment for age, Shone's complex and complex CHD were associated with an 11-fold and 8.8-fold increased hazard of death, respectively (p < 0.03). Freedom from autograft reintervention was 82% and from RV-PA conduit reintervention 66% at 25 years. Freedom from severe autograft dilatation was 71% at 20 years by absolute dimension and 54% when indexed to BSA. Greater than mild aortic regurgitation at discharge conferred a 17-fold risk of autograft intervention (p < 0.001). CONCLUSIONS: The Ross procedure provides excellent long-term survival and valve durability in children and adolescents, particularly those with isolated aortic valve disease. Autograft dilatation and conduit reintervention remain important late risks, reinforcing the need for lifelong surveillance in specialized centres.