What is done in the Ross procedure?

The Ross Procedure: Surgical Technique and Considerations

The Ross procedure is a complex operation that replaces the diseased aortic valve with the patient's own pulmonary valve (pulmonary autograft), while subsequently replacing the pulmonary valve with a homograft. 1

Surgical Technique

The Ross procedure involves several key steps:

1. Harvesting the pulmonary valve: The patient's own pulmonary valve is carefully excised
2. Aortic valve replacement: The pulmonary autograft is then used to replace the aortic valve using one of two main techniques:
   • Subcoronary implantation - placing the valve within the native aortic root
   • Full aortic root replacement - removing the native aortic root entirely and replacing it with the pulmonary autograft, with coronary arteries being reimplanted 1
3. Pulmonary valve replacement: The pulmonary position is then reconstructed using a homograft (typically a cryopreserved pulmonary homograft) 1

Technical Considerations

• Full aortic root replacement has become the preferred method of autograft implantation as it carries the lowest risk of pulmonary autograft failure 2
• Surgical reinforcement techniques (like pericardial strip buttressing) can be used to prevent dilation of the neoaortic sinuses 1, 3
• Some surgeons place the pulmonic valve within a Dacron conduit to prevent late complications 1, 3
• The procedure requires an experienced surgical team with exceptional expertise 1

Indications and Patient Selection

The Ross procedure is primarily indicated for:

• Young patients (typically under 65 years) requiring aortic valve replacement 1, 3
• Patients with contraindications to anticoagulation 1, 3
• Athletes with active lifestyles 3, 4
• Women contemplating pregnancy 3, 4
• Children with congenital aortic valve disease 5

Advantages and Disadvantages

Advantages:

• Avoids need for lifelong anticoagulation 1, 3
• Low incidence of thromboembolism 1
• Excellent hemodynamic efficiency 1, 3
• Low risk of endocarditis 1, 3
• Potential for growth in pediatric patients 1, 5
• Can restore long-term survival equivalent to age-matched healthy population 6, 4

Disadvantages:

• Complex operation requiring specialized surgical expertise 1, 3
• Higher risk of in-hospital mortality compared to standard AVR 1
• Risk of early aortic valve failure due to technical issues or aortic root dilation 1
• At least half of pulmonic homograft valves require intervention within 10-20 years 1, 3
• Reoperation can be challenging due to calcification and adhesions 3

Long-Term Outcomes

Studies show good long-term outcomes with the Ross procedure:

• Freedom from reintervention rates of 95% at 5 years, 88% at 10 years, and 81% at 15 years 6
• Excellent long-term survival comparable to age-matched general population 6, 4
• Linearized risk for reoperation of approximately 0.6% per patient-year for both the autograft and right ventricular outflow tract 6

Important Considerations

• The Ross procedure should only be performed at Comprehensive Valve Centers by surgeons experienced in this procedure 3
• Marfan syndrome is considered an absolute contraindication 2
• The procedure should be used with caution in patients with rheumatic valve disease and a dysplastic dilated aortic root due to higher risk of autograft dysfunction 2

The Ross procedure remains an excellent option for selected young patients with aortic valve disease, particularly when anticoagulation is contraindicated or undesirable, but requires careful patient selection and specialized surgical expertise.