Ross Procedure

The Ross procedure is a complex heart surgery that replaces a diseased aortic valve with your own healthy pulmonary valve. This procedure is often chosen for younger patients because it uses your own tissue, avoiding the need for lifelong blood thinners required by some other valve replacements. It aims to provide a durable solution for severe aortic valve problems.

What is Ross Procedure?

The Ross procedure is a specialized type of open-heart surgery that treats a damaged aortic valve. During this procedure, a surgeon replaces your diseased aortic valve with your own healthy pulmonary valve. A donor human valve (homograft) or, less commonly, a mechanical valve then replaces your pulmonary valve.

This surgery is unique because it uses your body's own tissue for the crucial aortic valve replacement. The aortic valve controls blood flow from your heart to the rest of your body. When it's diseased, it can narrow (stenosis) or leak (regurgitation), making your heart work harder. By using your own pulmonary valve (autograft) in the aortic position, the procedure aims to provide a living valve that can potentially grow with children and is less likely to cause blood clots. The pulmonary valve normally controls blood flow from your heart to your lungs. To replace the pulmonary valve, surgeons typically use a donor human valve. This donor valve is carefully selected and prepared. In some cases, a mechanical valve might be used for the pulmonary position, though this is less common.

Why it's done

The Ross procedure is primarily done to treat severe problems with the aortic valve, such as narrowing (stenosis) or leaking (regurgitation). It is often recommended for younger patients, including children, young adults, and women of childbearing age, because it can offer long-term benefits and avoids the need for daily blood-thinning medication.

When your aortic valve doesn't work correctly, it can strain your heart and lead to serious health issues. The Ross procedure is considered a good option for certain patients because it uses your own living tissue for the new aortic valve. This "autograft" can adapt better to your body over time. A key advantage of using your own pulmonary valve is that it typically does not require you to take blood-thinning medications (anticoagulants) for the rest of your life. These medications are often necessary with mechanical heart valves to prevent dangerous blood clots. For children, the autograft has the potential to grow as the child grows, which is a significant benefit. For athletes and women who plan to have children, avoiding blood thinners can also be a major advantage, reducing certain risks and lifestyle limitations.

How to prepare

Preparing for the Ross procedure involves several medical evaluations and tests to ensure you are healthy enough for surgery. Your care team will provide specific instructions, which usually include reviewing your medications, discussing your medical history, and making lifestyle adjustments like stopping smoking or certain medications before the procedure.

Before your surgery, you will undergo a thorough medical assessment. This typically includes physical exams, blood tests, and heart tests such as an electrocardiogram (ECG), echocardiogram (echo), and a chest X-ray. These tests help your doctors understand your heart's condition and overall health. Your doctor will review all medications you are currently taking. You may need to stop certain medications, such as blood thinners or anti-inflammatory drugs, several days or weeks before surgery to reduce the risk of bleeding. Always follow your doctor's specific instructions. You will also receive instructions about when to stop eating and drinking before the surgery. It's important to arrange for someone to drive you home after your hospital stay and to help you during your initial recovery period. Your medical team will answer any questions you have about preparation.

What happens during

During the Ross procedure, you will receive general anesthesia and a surgeon will make an incision in your chest to access your heart. Your heart will be temporarily stopped, and a heart-lung bypass machine will take over your heart and lung functions while the surgeon carefully removes your diseased aortic valve and replaces it with your pulmonary valve.

Once you are under general anesthesia, the surgeon will make an incision down the center of your chest, through your breastbone (sternum), to reach your heart. This is a type of open-heart surgery. To allow the surgeon to work on a still heart, you will be connected to a heart-lung bypass machine. This machine temporarily circulates blood and adds oxygen to it, taking over the functions of your heart and lungs. The surgeon will then remove your diseased aortic valve. Your own healthy pulmonary valve will be carefully removed and moved to the aortic position. A donor human valve (homograft) or, less commonly, a mechanical valve will then be placed in the pulmonary position. After the valves are secured, your heart will be restarted, and the bypass machine will be disconnected. The surgeon will then close your breastbone with wires and stitch the incision in your chest.

Recovery & timeline

After the Ross procedure, you will typically spend a few days in the intensive care unit (ICU) before moving to a regular hospital room. Most people stay in the hospital for about 5 to 7 days. Full recovery at home usually takes several weeks to a few months, involving gradual activity increases and often cardiac rehabilitation.

Immediately after surgery, you will be closely monitored in the ICU. You may have tubes for breathing, drainage, and medication. Pain medication will be given to manage discomfort. As you recover, these tubes will be removed, and you will gradually start to sit up and walk short distances. Once you leave the hospital, it's important to follow your doctor's instructions for activity. You will need to avoid heavy lifting and strenuous activities for several weeks. Most people can return to light activities and work within 4 to 8 weeks, but full recovery can take up to three months or more. Many patients participate in cardiac rehabilitation, a supervised program that includes exercise, education, and counseling. This helps you regain strength, improve heart health, and learn how to safely return to your daily routine. Regular follow-up appointments with your cardiologist are essential to monitor your new valves.

Risks & side effects

Like all major surgeries, the Ross procedure carries potential risks, including general surgical complications such as bleeding, infection, and stroke. Specific risks related to the Ross procedure include the possibility of either the new aortic valve (autograft) or the new pulmonary valve (homograft) failing over time, potentially requiring another surgery.

General risks associated with open-heart surgery include heart attack, irregular heart rhythms (arrhythmias), blood clots, kidney problems, and, rarely, death. Your medical team will discuss these risks with you before the procedure. Specific to the Ross procedure, there is a risk that the pulmonary valve used as the new aortic valve (autograft) could stretch or leak over time. Similarly, the donor valve placed in the pulmonary position (homograft) may also wear out or narrow, especially in children, and could require future intervention or replacement. While the Ross procedure avoids the need for lifelong blood thinners for the aortic valve, the pulmonary homograft may eventually need replacement. Regular follow-up with your cardiologist is crucial to monitor the function of both valves and address any potential issues early.

Success rate

The Ross procedure generally has good long-term outcomes, particularly for younger patients, with studies suggesting improved survival and fewer valve-related complications compared to mechanical valves in this group. While it involves two valve replacements, the long-term durability of the patient's own aortic valve (autograft) is a significant benefit, though the pulmonary donor valve may require reoperation over time.

For young adults with aortic valve disease, the Ross procedure is considered a highly effective treatment. It offers the advantage of using the patient's own living tissue for the aortic valve, which can lead to better long-term function and a lower risk of certain complications like stroke or bleeding that can occur with mechanical valves requiring lifelong blood thinners. While the autograft in the aortic position tends to be very durable, the donor valve (homograft) placed in the pulmonary position may not last as long. Over many years, there is a chance that this pulmonary homograft could narrow or leak, potentially requiring a second surgery to replace it. Despite the potential for future reoperation on the pulmonary valve, the overall long-term benefits for the aortic valve and the avoidance of chronic anticoagulation make the Ross procedure a successful option for carefully selected patients, providing good quality of life.

Frequently asked questions

How long does the Ross procedure last?

The surgery itself typically takes several hours. The benefits of the Ross procedure, particularly for the aortic valve, are designed to be long-lasting, often for many years. However, the donor valve placed in the pulmonary position may eventually need replacement over time.

Will I need blood thinners after a Ross procedure?

One of the main advantages of the Ross procedure is that you usually do not need to take lifelong blood-thinning medications (anticoagulants) for your new aortic valve, as it is made from your own tissue. If a mechanical valve is used for the pulmonary position, blood thinners might be needed, but this is less common.

Can the new aortic valve grow with a child?

Yes, a significant benefit of using your own pulmonary valve (autograft) for the aortic position is its potential to grow with a child. This makes the Ross procedure a particularly attractive option for pediatric patients, as it can reduce the need for future valve replacements as they get older.

What is the difference between Ross procedure and a standard aortic valve replacement?

In a standard aortic valve replacement, the diseased valve is replaced with either a mechanical valve or an animal tissue valve (bioprosthetic). The Ross procedure is unique because it replaces your aortic valve with your own pulmonary valve, and then a donor valve replaces the pulmonary valve. This avoids lifelong blood thinners for the aortic valve.

How soon can I return to normal activities after the Ross procedure?

Recovery varies, but most people can return to light activities and work within 4 to 8 weeks. Strenuous activities and heavy lifting should be avoided for several months. Full recovery, including participation in cardiac rehabilitation, can take up to three months or longer. Always follow your doctor's specific guidance.

What are the alternatives to the Ross procedure?

Alternatives for aortic valve disease include traditional aortic valve replacement with a mechanical valve (requiring lifelong blood thinners) or a biological tissue valve (which may wear out sooner but avoids blood thinners). Another option for some patients is transcatheter aortic valve replacement (TAVR), a less invasive procedure. Your doctor will discuss the best option for your specific situation.

Sources

• MedlinePlus — Ross Procedure
• Mayo Clinic — Ross Procedure
• Cochrane Library — Ross Procedure