What is the Ross aortic valve procedure indicated for?

Ross Aortic Valve Procedure: Indications

The Ross procedure is primarily indicated for younger patients with appropriate anatomy and tissue characteristics for whom anticoagulation is either contraindicated or undesirable, and should be performed only at Comprehensive Valve Centers by surgeons experienced in this procedure. 1

What is the Ross Procedure?

The Ross procedure is a complex operation involving:

• Replacement of the aortic valve with the patient's own pulmonic valve (pulmonary autograft)
• Placement of a pulmonic valve homograft to replace the harvested pulmonary valve

Primary Indications

Patient Characteristics

• Young patients (typically <65 years) 1
• Patients with congenital aortic valve disease 2
• Patients with contraindications to anticoagulation 1
• Women of childbearing age considering pregnancy 1, 3
• Physically active individuals 3

Clinical Scenarios

1. Aortic Stenosis or Regurgitation requiring intervention:

   • Particularly in young patients with bicuspid aortic valve disease
   • When other valve repair techniques are not feasible

2. Active Aortic Valve Endocarditis:

   • The Ross procedure has shown good resistance to infection
   • Long-term freedom from recurrent endocarditis (89.4% at 10 years) 4

3. Specific Situations:

   • When a mechanical valve is indicated but anticoagulation must be avoided
   • When a bioprosthetic valve would deteriorate too rapidly due to young age

Benefits of the Ross Procedure

• Excellent hemodynamics with normal valve function 2
• Avoidance of lifelong anticoagulation 1
• Growth potential in children 2, 5
• Restoration of long-term survival equivalent to age-matched healthy population 3
• Superior durability compared to bioprosthetic valves in young patients 6

Limitations and Considerations

• Technically demanding procedure 1
• Creates "double valve disease" (both aortic and pulmonary valves are affected) 5
• Risk of neoaortic valve regurgitation in the second decade after operation 1
• At least half of pulmonic homograft valves require reintervention within 10-20 years 1
• Higher risk of reoperation in very young children (≤2 years) 5

Patient Selection Algorithm

1. Age Assessment:

   • Optimal: Young and middle-aged adults (<65 years) 1, 3
   • Less optimal: Elderly patients (>65 years) who would benefit more from TAVR or standard SAVR

2. Valve Pathology:

   • Ideal: Aortic stenosis with small or normal aortic annulus 3
   • Acceptable: Mixed stenosis/regurgitation or pure regurgitation 2

3. Anticoagulation Status:

   • Preferred for patients who cannot take or wish to avoid anticoagulation 1
   • Essential for women planning pregnancy 1, 3

4. Surgical Expertise:

   • Must be performed at Comprehensive Valve Centers 1
   • By surgeons with specific experience in this procedure

Common Pitfalls to Avoid

1. Patient Selection Errors:

   • Performing the Ross procedure in older patients where conventional SAVR or TAVR would be more appropriate
   • Underestimating the technical complexity in centers with limited experience

2. Surgical Considerations:

   • Failure to recognize unfavorable anatomy that could complicate the procedure
   • Inadequate assessment of pulmonary valve suitability for autograft

3. Follow-up Issues:

   • Insufficient long-term monitoring of both the autograft and homograft
   • Delayed recognition of valve degeneration

Long-term Follow-up Requirements

• Lifelong cardiology follow-up is mandatory 1
• Regular echocardiographic assessment of both aortic and pulmonary positions
• Monitoring for autograft dilation and regurgitation
• Surveillance of the pulmonary homograft for stenosis or regurgitation

Despite the expanding evidence demonstrating long-term superiority over conventional prosthetic AVR in appropriately selected patients, the Ross operation remains underused and should be considered more frequently for young patients with aortic valve disease 3.