Improving outcomes of right ventricular outflow tract reconstruction during the Ross operation: Homograft decellularization and surgical technique.

Objectives: To evaluate the influence of decellularization and surgical technique in the cumulative incidence of homograft dysfunction and reinterventions after the Ross Operation. Methods: From 1995 to 2024, 414 patients underwent a Ross operation using cryopreserved (n = 161, median follow-up = 20.4 years) or decellularized homografts (n = 253, median follow-up = 9.1 years). Thirty-nine patients receiving decellularized homografts had a proximal conical extension of the homograft with decellularized human pericardium. Homograft dysfunction was defined as a peak gradient ≥40 mm Hg or pulmonary insufficiency moderate or greater. Results: The cumulative incidence of any dysfunction at 15 years was similar among the 2 groups (decellularized = 12.4%, vs cryopreserved = 11.2%). However, serial echocardiographic measurements revealed that peak gradients were lower in the decellularized homografts (β = -2.99, Conclusions: This study represent the longest follow-up with decellularized homografts during the Ross Operation. Decellularized homografts were associated with slower progression of late gradients and lower cumulative incidence of reoperations up to 15 years of follow-up. Conical extension with decellularized human pericardium may further improve their early and late hemodynamic performance.