What are the indications, management, and outcomes of the Ross procedure for aortic valve replacement?

The Ross Procedure: Indications, Management, and Outcomes

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

Indications

The Ross procedure is a complex operation involving replacement of the aortic valve with the patient's own pulmonic valve (pulmonary autograft), along with placement of a pulmonic valve homograft. This procedure is specifically indicated for:

1. Young patients - Particularly those under 65 years of age who require aortic valve replacement 1

2. Contraindications to anticoagulation - Patients who cannot or should not take anticoagulants, such as:

   • Athletes with active lifestyles 1
   • Women contemplating pregnancy 1, 2
   • Patients with high levels of physical activity 2

3. Specific anatomical considerations:

   • Patients with congenital aortic valve disease 3
   • Patients with aortic stenosis and small or normal size aortic annulus 2

Patient Selection

The ideal candidate for the Ross procedure is:

• A young, otherwise healthy adult with aortic stenosis 2
• Patient with appropriate anatomy and tissue characteristics 1
• Patient with a bicuspid aortic valve (common in Ross procedure candidates) 4
• Patient seeking to avoid lifelong anticoagulation 2

Management Considerations

Preoperative Assessment

• Coronary angiography is recommended before AVR in patients in whom a pulmonary autograft is contemplated when the origin of the coronary arteries has not been identified by noninvasive techniques 1
• Careful assessment of aortic root anatomy is essential, as preoperative aortic root dilatation is a risk factor for late autograft dilatation 4

Surgical Technique

Two main techniques are employed:

1. Root replacement technique - More common (86% in one study) 5
2. Subcoronary technique - Less common (14% in one study) 5

Technical modifications to prevent late complications include:

• Pericardial strip buttressing to prevent autograft dilatation 4
• Surgical reinforcement techniques to prevent dilation of the neoaortic sinuses 1
• Some surgeons place the pulmonic valve within a Dacron conduit 1

Postoperative Management

• Annual imaging of the aortic root is recommended to monitor for dilatation 4
• Early reintervention on dilated neoaortic root may enhance durability 4
• Regular echocardiographic follow-up to assess both the autograft and homograft function

Outcomes

Short-term Outcomes

• Operative mortality is low in experienced centers (0.9-1.5%) 3, 5
• Excellent immediate hemodynamics with normal functioning neoaortic valve 3
• Complete relief of left ventricular outflow tract obstruction in stenotic patients 3

Long-term Outcomes

• Survival: 10-year survival rates of 92-98% 4, 5

• Freedom from reoperation:

  • Overall Ross-related reoperation: 87.7-94.7% at 10-15 years 5
  • Autograft reoperation: 91.5-97.6% at 10-15 years 5
  • Homograft reoperation: 90.8-95.7% at 10-15 years 5

• Valve durability:

  • Freedom from moderate/severe autograft regurgitation: 85.6-94.1% at 10-15 years 5
  • Evidence of autograft growth in pediatric patients 3

Complications

1. Autograft dilatation - Occurs in approximately 29% of patients at 10 years 4
2. Autograft regurgitation - Occurs in approximately 14% of patients at 10 years 4
3. Homograft stenosis - Occurs in approximately 5% of patients 4
4. Risk factors for autograft dilatation:
   • Younger age
   • Preoperative aortic root dilatation
   • Root replacement technique
   • Absence of pericardial strip buttressing 4

Advantages and Limitations

Advantages

• Avoids need for anticoagulation 1, 2
• Provides excellent valve hemodynamics 1, 6
• Potential for growth in pediatric patients 3
• Restoration of long-term survival equivalent to age-matched healthy population 2
• Superior long-term outcomes compared to prosthetic AVR in selected patients 2, 6

Limitations

• Complex procedure requiring specialized surgical expertise 1
• Risk of reoperation on both the autograft and homograft 1
• Failure of the Ross procedure most often due to regurgitation of the neoaortic valve in the second decade 1
• At least half of pulmonic homograft valves require intervention within 10-20 years 1
• Calcification of the homograft and adhesions may increase difficulty of reoperation 1

Conclusion

Despite the expanding evidence demonstrating long-term superiority over conventional prosthetic AVR in appropriately selected patients, the Ross procedure remains underused 2. When performed in expert centers with adequate surgical volumes, it offers excellent long-term outcomes for young patients with aortic valve disease who wish to avoid anticoagulation. However, patients must understand the potential need for reintervention and the importance of lifelong follow-up.