Despite nearly four decades of experience, the role of pulmonary valve
autotransplantation (Ross procedure) in the treatment of
aortic valve disease in adults and children continues to evolve and remains controversial. As the picture of late results has unfolded, alternating waves of enthusiasm and caution have characterized its use and have led to ongoing refinements in indications and operative technique. At present, it is seen as indispensable in the treatment of
aortic valve disease in infants and small children (for whom no satisfactory replacement alternative exists and for whom growth is essential), attractive for adolescents and young adults who wish to avoid
anticoagulants because of childbirth and lifestyle considerations, a reasonable option for selected adults who desire
biologic solutions with potentially better durability than conventional
bioprostheses, and contraindicated for the elderly and those with connective tissue disorders. Young patients with
bicuspid aortic valve are the most common potential recipients, but also the most controversial, because of the risk of autograft dilatation. Optimal matching of
prosthesis to patient is a clinical challenge for all caretakers involved in the treatment of
valvular heart disease; this review provides guidelines to identify those patients who will benefit most from the Ross procedure, and those for whom it is inadvisable.