Aortic valve replacement in young and middle-aged adults: looking beyond the tree that hides the forest

The ideal aortic valve substitute for young and middle-aged adults with aortic valve disease remains elusive. Owing to a longer anticipated life expectancy, these patients present a higher cumulative lifetime risk of prosthesis-related complications. Conventional prosthetic valves expose the young patient to the virtual inevitability of a reoperation in the case of bioprosthetic valves or the continuous hazards of thrombosis and bleeding in the case of mechanical valves. In the long run, this translates into excess mortality compared to the general population. The Ross procedure offers unique advantages and is the only operation that has shown the potential to restore a normal life expectancy in young and middle-aged adults with severe aortic valve disease. Despite these advantages, its use has declined dramatically in recent years due to concerns over technical complexity, perioperative complications, and longterm autograft failure. These concerns can be largely mitigated by adequate patient selection and careful attention to minute technical details. In the current era, the Ross procedure can be performed safely and reproducibly in centers of excellence. Furthermore, several recently published studies have demonstrated superior long-term outcomes with the Ross operation compared to mechanical aortic valve replacement in young and middle-aged adults. In this article, we argue that the under-use of the Ross operation represents a missed opportunity that is mainly driven by an excessive focus on perioperative outcomes at the expense of long-term results.