What is the Ross procedure and when is it recommended for patients with aortic valve disease?

The Ross Procedure: Indications and Recommendations

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

What is the Ross Procedure?

The Ross procedure involves:

• Replacement of the aortic valve with the patient's own pulmonary valve (pulmonary autograft) 1
• Placement of a pulmonary valve homograft to replace the harvested pulmonary valve 1
• Creation of a living valve substitute with excellent hemodynamics and avoidance of anticoagulation 1

Key Benefits of the Ross Procedure

• Avoidance of lifelong anticoagulation therapy 1
• Excellent valve hemodynamics with normal blood flow patterns 1, 2
• Potential for growth in pediatric patients 3
• Resistance to infection 4
• Restoration of normal life expectancy in appropriate candidates 2

Primary Indications

The Ross procedure is primarily indicated for:

• Young patients (typically <50 years of age) with aortic valve disease 1, 5
• Patients with contraindications to anticoagulation therapy 1
• Women of childbearing age contemplating pregnancy 5, 4
• Physically active individuals who require optimal hemodynamics 5
• Children with congenital aortic valve disease 3
• Patients with a bicuspid aortic valve and small aortic annulus 4

Contraindications

• Marfan syndrome is considered an absolute contraindication 4
• Caution is advised in patients with rheumatic valve disease 4
• Patients with a dysplastic dilated aortic root may have higher risk of autograft dysfunction 4

Long-term Outcomes and Durability

• Survival rates at 10 years approach 94% 2, 6
• Freedom from autograft replacement at 10 years is approximately 100% in some series 6
• The need for reintervention increases during the second decade after surgery 2
• Cumulative incidence of any reintervention at 20 years is approximately 45% 2
• Failure of the Ross procedure is most often due to regurgitation of the neoaortic valve in the second decade 1
• At least half of pulmonic homograft valves require reintervention within 10-20 years 1

Important Considerations and Caveats

• The procedure should only be performed by experienced surgeons with exceptional expertise 1
• The technique of total aortic root replacement has become the preferred method of autograft implantation 4
• Calcification of the homograft and adhesions may increase the difficulty of reoperation 1
• The procedure creates double-valve disease, which is a significant consideration 6
• Young children (≤2 years old) may have higher rates of homograft replacement during follow-up 6

Current Guideline Recommendations

According to the 2020 ACC/AHA guidelines, the Ross procedure:

• Is typically reserved for younger patients with appropriate anatomy 1
• Should be performed only at Comprehensive Valve Centers by experienced surgeons 1
• May be considered in young patients when anticoagulation is contraindicated or undesirable (Class IIb recommendation) 1

Despite expanding evidence demonstrating its long-term superiority over conventional prosthetic AVR in appropriately selected patients, the Ross operation remains underutilized 5.