The times are changing for the Ross procedure as it settles itself as the best alternative for valve replacement not only in young adults, but also, as the study by Notenboom et al. in this issue of the European Heart Journal demonstrates, in the paediatric population.¹ We have learned recently that performing a mechanical or bioprosthetic valve replacement rather than a Ross procedure in young adults between 20 and 40 years of age is likely to shorten their life by 20 years, while the Ross procedure provides a survival equal to that of the general population.^2–4 This team now demonstrate a similar survival advantage in the paediatric population but with a lower extent. Their survival with the Ross procedure is expected to be 95% of that of the normal population, comparing favourably with the 85% offered by mechanical valves, a remarkable achievement considering that many of those undergoing the Ross procedure had inextricably complicated issues and that many were operated on at such a young age that mechanical valve replacement was not an option. Many of the operations performed in the neonatal period were probably emergent operations after failed balloon valvuloplasty which has been shown to reach a mortality of up to 30%.⁵ The calculated event-free survival after the Ross procedure was double that provided by mechanical valve replacement, despite the Ross procedure being performed in a younger population.

This finding is even more remarkable because the design of this study would normally not favour the more technically demanding procedure. The team of Takkenberg have included in this complex meta-analysis all reported studies spanning three decades, thereby comprising the entire experience with the Ross procedure, including the learning curves of all centres. It has become clear in the field of cardiac surgery that if one wants to evaluate the potential benefit of a technically demanding procedure, one should rather evaluate the long-term outcomes of one best centre, or even one expert individual. Performing multicentric studies will always put the technically demanding procedure at a disadvantage.