The Ross Procedure After Previous Aortic Valve Surgery: Propensity-Weighted Comparison of Mid-Term Outcomes.

OBJECTIVE: We aimed to compare mid-term clinical, hemodynamic, and reintervention outcomes of the Ross procedure performed in primary versus reoperative settings in adults. METHODS: We analyzed 816 consecutive adults undergoing the Ross procedure at the Montreal Heart Institute between 2011 and 2025: 83 (10.2%) underwent a Ross after at least one prior aortic valve operation (redo Ross) and 733 (89.8%) underwent primary Ross. Propensity-score overlap weighting balanced nine pre-specified covariates (age, sex, NYHA, left ventricular ejection fraction, bicuspid morphology, pure aortic stenosis, pure aortic regurgitation, endocarditis, and preoperative aortic regurgitation grade); 1:1 propensity matching served as sensitivity. Survival was compared using overlap-weighted Kaplan-Meier. Reintervention was modeled with Aalen-Johansen competing-risk methods. Longitudinal echocardiographic trajectories were analyzed with weighted generalized estimating equations. RESULTS: Operative mortality was 2.4% (redo) versus 0.3% (primary, P=0.054). Over a median follow-up of 5.0 years (IQR 1.6-8.4), redo Ross was associated with higher all-cause mortality after overlap weighting (HR 3.92, 95% CI 1.41-10.94, P=0.009). Reintervention was numerically more frequent (HR 2.68, 95% CI 0.93-7.75, P=0.069) but not statistically significant. The redo group exhibited a consistently larger absolute sinus of Valsalva diameter from the postoperative period through ten years, with differing dilation rates. Freedom from autograft regurgitation ≥ 2+ was comparable. CONCLUSIONS: The Ross procedure can be performed safely in adults after prior cardiac surgery. Prior surgery does not protect the autograft against progressive root dilatation in adults, supporting continued imaging surveillance irrespective of operative history.