The Ross procedure at the crossroads: lessons from biology: is Dr Ross's dream concluded?

The latest reports on the long-term outcome of Ross operation dropped a veil of uncertainty on the future of this life-saving procedure. The potential for pulmonary autograft dilation and failure in growing children led to resize the importance of this operation and favored the reappraisal of other techniques. Nevertheless, the idea of using the autologous pulmonary trunk to replace the diseased aortic valve remains an "evergreen" and techniques of reinforcement of the pulmonary autograft with synthetic materials have been developed. However, these strategies did not produce the expected benefits and the reasons underlying their failure need to be found in the fact that these materials do not respect tissue and cellular biology of a living and growing structure. A renovated attention should be paid to the biological processes occurring after our intervention and to the lessons that the nature wants to give us. Data on experimental approaches obeying to these warnings and respecting biological processes are increasingly available and we believe that this could be a key point to give an immediate future to the Ross procedure and to stimulate further research on the development of bio-artificial vascular substitutes.