Ross Procedure Sections: Introduction | History | Anatomy | Pros & Cons | Patient Selection | Technique | Results | Pediatric Ross

Patient Selection

Not every patient is a candidate for the Ross procedure. The surgeons goal is to wed the proper valve substitute to the patient according to the anatomy and physiology that best suits that particular situation. Surgical judgement is needed to decide when the benefits of the autotransplant operation outweigh the potential disadvantages. For a further discussion on the advantages and disadvantages, please review the section on Pros and Cons.

Candidates for the Ross procedure must demonstrate significant aortic valve disease, either stenosis, regurgitation, or both. In the advanced stages, aortic valve disease can cause chest pain (angina), fainting during exercise, exertional shortness of breath, or congestive heart failure. Once symptoms occur, patients should recieve a new aortic valve to prevent serious consequences and death. Even before symptoms occur, some patients need surgery to prevent thickening and/or dilation of the heart, arrythmias, or to reduce the risk of sudden death. Echocardiograms and invasive testing such as cardiac catheterization will be needed to determine if the aortic valve and the heart have declined enough to warrant surgical intervention.

The calcification and leaflet stiffening typically seen in chronic aortic valve disease makes it difficult to repair the native valve in most cases. Valve replacement is still superior to repair operations in nearly all circumstances. For those patients whose anatomy and/or symptoms have progressed to the point of surgical intervention, there are a number of options. Mechanical and tissue prosthetic valves are the most common replacement devices in use today. Each has their own advantages and disadvantages. However, in many situations, the Ross procedure is now clearly the most effective treatment for aortic valve disease. The main advantages of the pulmonary autotransplant (as compared with a prosthetic valve implant) are:

• No artificial material is used for the "new" aortic valve.
• All reconstructions are done with natural materials.
• The crucial aortic valve reconstruction is performed entirely with the patients own pulmonary valve.
• No matter the size of the patient, a gradient free aortic valve reconstruction can be obtained.
• The only natural, potentially curative replacement for the aortic valve in small children or infants.
• In growing children, the autotransplant is the only aortic valve replacement that provides a living, viable graft which will grow as the child grows.
• The patients pulmonary valve is the right size and always available as a sterile graft.
• The autotransplant is not rejected (since it comes from the patients own tissues),
• No blood thinners are required
• The autotransplant is noiseless (unlike most mechanical valves).
• Patients can participate in any level of physical exertion they desire, including professional sports.
• The current operative morbidity and mortality rates are very low, and nearly equal to prosthetic valve implants.

Despite the advantages listed, not every patient is best served by the Ross operation. In some situations, a conventional prosthetic valve would be best. For instance, the autotransplant procedure takes longer and is more detailed than valve replacements performed with either tissue or mechanical prostheses. Patients with other medical or cardiac problems (such as mitral valve or coronary artery disease) may not tolerate the operation. Currently, the Ross procedure is recommended primarily for patients with aortic valve disease and no other major cardiac problem. Within this group, the pulmonary autotransplant is an excellent choice for patients...

• Who are less than 55 years of age (at the time of anticipated surgery) ... and ..
• Who have a life expectancy of 20 years or more ... or ...
• Who have a definate contraindication to anticoagulation, such as a history of bleeding . (regardless of age)
• Woman of childbearing years
• No other major cardiac lesion needing correction (multivessel coronary disease, mitral disease) except ascending aneurysm or mild to moderate root dilatation.

A special group of patients for which the Ross operation is ideally suited are children with aortic valve disease. Any prosthetic valve implant used in a small child will become inadequate as the patient grows. This vexing problem has required most children to undergo multiple operations for the treatment of symptomatic congenital aortic valve disease. A special section of this symposium is presented for discussing the Ross procedure in children.

In the adult, growth of the patient following surgery is not a consideration. However, a women of child bearing age represents a challenge of another kind. The age range of child bearing is roughly from the onset of menstruation (about 12 years of age) to menopause (age 40 - 45 years old). Any valve substitute chosen for a female patient within those age ranges must be capable of many decades of uninterrupted performance. At the same time, mechanical valves require Coumadin® to prevent thromboembolism (clot formation leading to stroke or other tragic consequences). Coumadin® taken by the pregnant mother can cause birth defects in the fetus. Thus any heart valve replacement in a woman of child bearing years must permit her to exist safely without the burden of anticoagulation. Unfortunately, porcine or bovine tissue valves, and human homograft valves do not last long enough to be an effectively curative operation in a young woman. Additionally, the smaller body size and aortic annular size of the female makes it a challenge for the surgeon to implant a valve of sufficient size that no residual obstruction remains.

In this age range, the Ross procedure has unique and special advantages. Firstly, regardless of the age of the female patient, the Ross autotransplant recipient does not need Coumadin® . At the same time, the liklihood of future valve operations is quite low. Any remaining growth of the premature teenager can occur in the autotransplant, making this operation superior to any fixed-size valve substitute.

In adult patients with anticipated long remaining lifespan (greater than 20 years), valve durability is one of the major issues in surgical decision making. A mechanical prosthesis has clear superiority in terms of durability within all age ranges and sizes. However, the burden of anticoagulation over a long period of time is not insignificant. Thus, for many patients who have no life limiting diseases (other than their heart valve problem), the Ross autotransplant is a very attractive and successful operation.

After 55 to 60 years of age, the choices change. In the older adult, coronary artery disease (CAD) is a additional finding commonly discovered during the preoperative evaluation of patients with heart valve disease. Significant CAD weighs against doing a Ross procedure, since the combined complexity of simultaneous coronary artery bypass grafting (CABG) and the Ross is far too much surgery at one time. Thus patients with CAD are usually selected for a mechanical valve (plus CABG) if less than age 70 or a tissue valve (plus CABG) after age 70. If any contraindications to Coumadin® exist (at any age), a tissue valve is then preferred. In any patient with a small aortic root, the modern mechanical valve designs still have superior performance and provide the best fit when compared to tissue valves. Also, there are some patients who will be required to take anticoagulation for life regardless of the issue of valve substitute. Such patients are individuals in whom chronic atrial fibrillation, left atrial thrombosis (clot), or stroke have already occurred as a consequence of their heart or valve disease. In these patients, it is not wise to place a substitute that will avoid Coumadin® since there are already strong indications to use long term anticoagulation. Thus these patients should have a durable and lifelong mechanical valve implant and continue taking their Coumadin®.

It is important to remember that the selection of a valve operation is unique in each case. Surgeons are very adapted to evaluating the needs of the patient and individualizing the operative approach to that patients needs. And not all situations can be anticipated in advance. Some decisions must be made in the operating room while the patient is asleep and undergoing the procedure. For instance, when the surgeon encounters an aortic annulus that is too small for a tissue valve (less than 23 mm in circumference), it is best to switch to an efficient mechanical design at that point. The discovery of valve infection at the time of operation can also affect the surgeons choice of valve type. In the Ross procedure, it is rare (but possible) to find the pulmonic valve unsuitable for use as an autotransplant, in which case another type of valve operation (mechanical, xenograft, or homograft) should be performed instead.

Some investigators believe that the pulmonary autograft will age in synchrony with the aging process of the patient as a whole. Thus they do not recommend this operation in patients over 45 years of age. However, there is no current data to support any such concern.

The following conditions are considered relative contraindications to using the pulmonary autotransplant procedure...

• Coronary Artery Disease (due to the length of operation and limited life expectancy concerns).
• Simultaneous mitral valve disease requiring surgical correction.
• Obesity (medical comorbidity plus added operative risk).
• Chronic Obstructive Pulmonary Disease (C.O.P.D) or Emphysema.
• Marfans' syndrome (since pulmonary valve is also affected).
• Connective tissue disorders (Systemic Lupus Erythematosis (SLE, Rheumatoid Arthritis (RA) since they can also affect the pulmoary valve).
• Any structural abnormality of the pulmonic valve (as evidenced by preoperative exam or echocardiogram).

Ross Procedure Sections: Introduction | History | Anatomy | Pros & Cons | Patient Selection | Technique | Results | Pediatric Ross

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