The Ross procedure is a type of heart valve replacement surgery to replace an aortic valve that is severely narrowed (stenosis) and/or improperly closing, allowing blood to leak back in the wrong direction (regurgitation). Oxygen-rich blood is normally pumped from the heart, through the aortic valve and out the aorta to the rest of the body. If the aortic valve is defective, then the rest of the body could be damaged from a lack of oxygen.
The Ross procedure is a two-step procedure. First, the surgeon replaces the aortic valve with the patient’s healthy pulmonic valve. The pulmonic valve allows oxygen-poor blood to travel from the right ventricle into the pulmonary artery, where it is carried to the lungs. Second, during the same surgery, the physician replaces the pulmonic valve with a valve from a cadaver (homograft). The main advantage of the Ross procedure is that the new aortic valve will grow with the patient, which is very important for children who are born with a heart defect.
The Ross procedure is an open-heart surgery that takes about five hours, and the patient will remain in the hospital for nearly a week. The success rate of the surgery is over 90 percent. After the surgery, the patient may need to take antibiotics before any dental, medical or surgical procedures to reduce the risk of a potentially fatal inflammation called endocarditis.
The International Registry of the Ross Procedure lists cardiac surgeons throughout the world who perform the Ross procedure.
About the Ross procedure
The Ross procedure is a type of heart valve replacement surgery to replace an aortic valve that is either severely narrowed (stenosis) or improperly closing, allowing blood to leak back in the wrong direction (regurgitation). During the open-heart surgery, the defective aortic valve is replaced by the patient's own pulmonic valve, which is then replaced with a new pulmonary valve from a deceased human donor (homograft valve). Because the pulmonic valve is removed and then replaced, this surgery is also known as pulmonic valve translocation.
Although adult patients sometimes undergo this surgery, it is usually performed on young patients who have had valvular heart disease since birth (congenital heart disease). Adult candidates who are sometimes recommended for this procedure include those who are less than 50 years of age, have experienced valve failure from a previous valve replacement, and/or suffer from endocarditis. Use of the Ross procedure is somewhat controversial among people older than 60 years of age, at least in part because the pulmonic valve is not as elastic in older patients. Additionally, the length andcomplexity of the surgery increase the risk of surgical complications.
The best candidates for this procedure include those who
Are under age 55 and can expect to live at least another 20 years. The procedure is often recommended for athletes or for women of reproductive age.
Have no other significant heart or valvular disease. It is especially important for the patient to be free of any problems with the pulmonic valve or depressed function of the left ventricle. Another specific disease that cannot be present is Marfan syndrome (a genetic disorder of the connective tissue that can significantly affect cardiac function).
Do not have advanced coronary artery disease.
Are unable to tolerate anticoagulant medication. Mechanical aortic valve replacement requires the use of lifelong anticoagulation treatment, while the use of a native pulmonic valve means the patient will not require anticoagulation.
This surgery was first developed in 1967 by a British surgeon named Sir Donald Ross, and it has since been performed many times around the world with a high success rate.
Role of valves in cardiac blood flow
In a normally functioning heart, each of the four valves has its own set of “gates” or flaps that swing open to let blood flow from one area to the next. After opening, the flaps should neatly close again until the next cycle begins. Thus, blood should flow only in one direction and only at the right time. The route blood travels through the heart is:
Oxygen-poor blood returns to the right side of the heart from the rest of the body, via the veins, and enters the right atrium. From the right atrium, it passes through the tricuspid valve into the right ventricle. From the right ventricle, it is pumped through the pulmonic valve and into the pulmonary artery, which carries the blood to the lungs for more oxygen.
Oxygen-rich blood returns from the lungs to the left side of the heart via the pulmonary veins, and then travels to the left atrium. From the left atrium, it passes through the mitral valve and into the left ventricle. From the left ventricle, it is pumped through the aortic valve (sometimes referred to as the “gatekeeper” of the heart) and out the aorta to nourish the rest of the body.
A diseased aortic valve can cause complications with the flow of blood out of the left ventricle, through the aorta and to the rest of the body. As a result, the organs, cells and tissues will receive less oxygen-rich blood and the structure of the heart itself can be affected. For example, the heart chambers may work harder in an attempt to overcompensate for this shortcoming, leading to an enlargement in size and other potential conditions, including abnormal heart rhythms (arrhythmias). Therefore, heart valve replacement surgery is highly recommended for patients with these conditions.
Advantages and disadvantages of the Ross
In general, the prognosis after this surgery is good. Several studies have shown a 20-year survival rate of around 60 percent, with a low incidence of major complications. Patients can expect to enjoy a prolonged and improved quality of life. Other advantages of the Ross procedure for those patients who qualify include the following:
The pulmonic valve is the same size as the aortic valve and will grow at the same rate as the rest of the heart, which is especially important in children. The valve from the cadaver (homograft) will, of course, not grow and may need to be replaced at some point.
In contrast with a mechanical valve, the homograft valve used to replace the pulmonic valve is less likely to show complications, such as blood clots or impaired blood flow. However, a minority of patients (between 15 and 20 percent) may need to have the pulmonic valve replaced.
In the future, physicians hope to improve the Ross procedure by developing tissue-engineered pulmonic valves. These tissue-engineered valves are created from the patient’s own tissue, so there is no need for a mechanical or homograft valve. This eliminates the possibility of a tissue rejection. The tissue-engineered valves are created using cells from the patient’s body that are grown on a scaffold valve. After implantation, the scaffold is absorbed by the body, leaving only the new pulmonic valve. This experimental technique has only been used in a few patients, but early results have been promising.
Although the success rate of the Ross procedure is high, there are certain factors for patients to consider. The Ross procedure is a double valve replacement, making it more technically demanding and complex than single valve replacement surgeries. It should only be performed by highly trained, highly skilled cardiac surgeons who perform many of these operations every year.
In some cases, physicians may prefer to simply replace the dysfunctional aortic valve (heart valve surgery replacement) rather than attempt the Ross procedure. Finally, the use of the Ross procedure in patients over 60 years of age is controversial because of the possibility of complications.
Before the Ross procedure
The patient is usually admitted on, or a day before, the scheduled date of surgery. In the hospital, the patient will undergo a battery of tests. Even if these tests were already done days or weeks before surgery, they will be performed again just prior to surgery to be sure that the patient’s medical condition has not changed. They include the following:
Urine and blood tests. These are done to ensure that the patient is in good overall health for undergoing surgery. Blood tests to assess blood clotting (coagulation tests) include an INR or prothrombin time (PT), partial thromboplastin time (PTT), bleeding and clotting times, and a platelet count.
Electrocardiogram (EKG). A recording of the heart’s electrical activity as a graph on a moving strip of paper or video monitor.
Chest x-ray. A radiation-based imaging test that offers the physician a picture of the general size, shape, and structure of the heart and lungs.
Eight hours before surgery, all patients are placed on NPO (non per os; nothing by mouth) status. That means they are not permitted to eat, drink or take anything by mouth until after their surgery. Adult patients who smoke will have been instructed to completely avoid smoking for at least two weeks before their surgery to prevent problems in blood flow, clotting or breathing. Certain medications may need to be reduced or stopped temporarily, so medication schedules should be discussed with the cardiologist before surgery.
Approximately one hour before surgery, the patient will be given specific pre-operative medications and then “prepped” for surgery. First, the chest area is shaved (if necessary). Next, an intravenous (I.V.) line will also be started, usually in the forearm or back of the hand.
The patient is then given a sleep-inducing medication through the I.V. to start anesthesia. The patient will continuously breathe a mixture of oxygen and anesthetic gas to make sure that he or she remains asleep throughout the entire surgery.
During the Ross procedure
After the patient is asleep, a device called the Swan-Ganz catheter is often inserted into the jugular vein (in the neck) and threaded to the pulmonary artery (which goes from the heart to the lungs). This catheter is used to give medication, to measure the oxygen levels in the blood and to measure pressures in the heart. A breathing tube (endotracheal tube) will also be inserted into the mouth and down the windpipe (trachea) to maintain an airway.
An incision is made through the chest and breastbone (sternum). A heart-lung machine is used to take over the functions of the heart so that it can be safely stopped during the procedure. Next, the surgeon will open the aorta and inspect the aortic valve to ensure that the aortic root is indeed viable for this procedure. If so, the diseased aortic valve and accompanying tissue are removed.
Next, the pulmonary root and a segment of the pulmonary artery are inspected for suitability, harvested and implanted in the position of the aortic root and the diseased aortic valve. A preserved pulmonic valve from a deceased human donor is implanted in the original position of the pulmonary valve. Once the procedure is completed, the heart incision is closed, the heart is restarted, blood circulation and oxygen are restored to the heart, bypass circulation is suspended and the chest incisions are closed. A transesophageal echo will be performed during the surgery to evaluate the new valves’ function. The procedure may take four to six hours.
After the Ross procedure
After surgery, the patient will be transferred to a cardiac intensive care unit, where he or she will be monitored continually. The patient will be placed on a respirator, which will assist the patient with breathing. Once it is decided the patient can breathe independently, the breathing tube and respirator will be removed. Painkillers may be administered, blood samples will be taken and electrocardiogram (EKG) monitors will provide immediate feedback about the procedure’s success. Subsequent tests will be performed once or twice a year to monitor the patient's heart health.
The cardiologist will discuss further medical treatment, including the use of pain medications, antibiotics or anticoagulants. He or she will also update any medications the patient had already been taking.
Barring any unforeseen complications, an individual will typically spend less than a week in the hospital before being discharged. Patients may be able to return to normal activity within six weeks, but this varies from patient to patient and must be approved by the patient’s cardiologist and surgeon. The chest scar, anywhere from 7 to 11 inches long, will fade within the first year.
Potential risks of the Ross procedure
Complications, which are relatively uncommon, may include the following:
Excessive bleeding
Infection at the incision site
Circulation disorders, including fluid retention and swelling (edema)
Kidney damage or failure
Numbness in the face, arms or legs
Breathing difficulties
Heart attack
Cardiac arrest
Deep vein thrombosis (the formation of blood clots in the deep veins, usually of the legs)
Stroke
Infection in the area of the incision or in the heart itself
Heart failure
Early valve failure
As with many invasive procedures, risk increases with:
Advanced age
Decreased left and right ventricular function
Obesity (body mass index of 30 or greater)
Excessive use of alcohol and/or drugs such as sedatives, sleep inducers and narcotics
Use of certain medications, such as antihypertensives (which treat high blood pressure) and muscle relaxants
As with some other conditions, patients may be advised to take antibiotics before any medical procedures, surgeries or dental work. These medications can reduce the risk of the patient developing a potentially fatal inflammation called endocarditis.
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients or parents may wish to ask their doctor the following questions related to the Ross procedure:
What makes me a candidate for the Ross procedure?
What diagnostic tests will I need before surgery?
What are the risks associated with the procedure?
Are there any alternate treatments available to me?
Do I need to do anything to prepare myself for the procedure?
How successful do you expect the procedure to be?
What is the recuperation period following surgery?
How will you determine if the procedure is successful?
Will I have any restrictions in lifestyle after this procedure?
How experienced is the surgeon who will be performing the procedure?
What are the chances that I will surgery again later in life?
What type of tests and on what schedule will I need to monitor my heart function?
Are my children at risk for the same hearth defect?
