Adults who underwent the Ross procedure saw overwhelmingly “excellent” long-term outcomes 25 years later, according to a study published in the Journal of the American College of Cardiology.

This is one of the most extensive studies of long-term outcomes in Ross patients, Elisabeth Martin, MD, MPH, and colleagues wrote in the study. While pulmonary autograft procedures remain a controversial option for patients in need of aortic valve replacement, recent guidelines have recommended the Ross procedure—an operation in which a patient’s damaged aortic valve is replaced with a healthy pulmonary valve—as a viable treatment option, especially for younger patients.

“Benefits of this operation, such as low pulmonary autograft thrombogenicity, absence of anticoagulation, potential valvular growth for young patients and favorable autograft hemodynamic measurements have all been reported,” Martin and co-authors wrote. “Previous publications have also shown that patients’ survival following the Ross procedure was not significantly different from the general population.”

Indeed, the research team found that of 310 adults who underwent the Ross procedure between 1990 and 2014 at the Quebec Heart and Lung Institute, related reintervention was required in a minority of the patients two decades later, and overall mortality remained low.

More than 70 percent of the study pool—227 patients—were diagnosed with bicuspid aortic valve, according to the study, and needed surgery due to aortic stenosis. Ten years after the procedure, those patients saw 92.9 percent freedom from any Ross-related reintervention, and 20 years later, 70.1 percent were still healthy.

Four patients died in-hospital, Martin and colleagues reported, and risk factors for pulmonary autograft degeneration were preoperative large aortic annulus, preoperative aortic insufficiency and concomitant replacement of the ascending aorta.

Still, overall survival at 10 and 20 years was 94.1 percent and 83.6 percent, respectively, in all patients. The team also wrote long-term survival didn’t differ largely between patients who required Ross-related reintervention and those who didn’t, though long-term survival when compared to a general population was much lower in patients who underwent the Ross procedure.

“We report excellent long-term survival with very low valve-related mortality following the Ross procedure,” the authors wrote. “Yet all-cause mortality was higher than in a sex- and age-matched population. Future studies should integrate data from multiple institutions to better define optimal autograft implantation techniques and postoperative management.”

The team also suggested the Ross procedure for younger adults in cases where pulmonary valve autograft is risky. Though it’s technically more challenging and isn’t as widely used, Martin and co-authors wrote, its results speak for themselves.