• Federica Caldaroni, Peter Skillington, Michael O'Keefe, Edward Buratto, and Rochelle Wynne.
• Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
• J. Thorac. Cardiovasc. Surg. 2025 Jan 19.

BackgroundIn adults, the Ross procedure provides an excellent alternative to prosthetic valves, but it is underutilized because of concerns about technical complexity, durability, and perceived high late reoperation rates. The inclusion technique stabilizes the aortic root, prevents dilatation, and respects the dynamic root physiology. Long-term outcomes of the Ross procedure with the inclusion cylinder technique (1992-2022) are reported.MethodsLong-term (12.2 years; 95% CI, 11.5-12.8) single institution results, with more than 25 years of follow-up in 44 patients. A total of 516 patients aged 39 ± 13 years underwent Ross procedure with inclusion cylinder and annular reduction. All had yearly clinical review and biannual transthoracic echocardiogram. The etiology of valve disease comprised aortic stenosis (AS) (n = 233 [44.8%]), aortic regurgitation (AR) (n = 179 [34.4%]), and mixed AS/AR (n = 108 [20.8%]). The primary end points were 25-year survival and freedom from reoperation, with degree of autograft regurgitation in all morphologies (AS, AR, and mixed AR/AS) as the secondary end point.ResultsTotal reoperation rate was 8.3% after 25 years (n = 43; aortic valve = 28, pulmonary valve 15), with early reoperation (<1 year) in 0.6% and early postoperative death in 0.2% following myocardial infarction. Overall, 25-year survival was 85.3%, and 25-year freedom from autograft reoperation was 89.5% (AS = 95.0%, AR = 78.0%, and mixed AS/AR = 94.3%) (P = .01). Freedom from redo pulmonary valve replacement was 92.7%.ConclusionsThe Ross procedure with inclusion cylinder technique provides excellent hemodynamics. Autograft inclusion in the native aorta minimizes prosthetic material and respects physiological root changes, reducing shear stress on neoaortic cusps and increasing durability. Long-term reoperation rate is low in experienced centers.Copyright © 2025 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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