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

Results

The original Ross pulmonary autotransplant was performed in 1967. However, the current surgical techniques were not refined until at least 1976. Since that time, the results have improved dramatically. It is now apparent that long term survival and freedom from complications for sugically treated patients with aortic valve disease is better with the Ross procedure than any other form of aortic valve replacement. Postoperative patient survival at 20 years is an impressive 70% overall, making this operation the ideal choice for younger patients with aortic valve disease, or anyone with an anticipated life expectancy of more than 20 years following surgery.

More than 2 decades following surgery, only 15% of patients required any additional valve procedures and most of these were replacement of the right ventricular reconstruction, not the aortic substitute. Fortunately, it is easier and less morbid to replace the right ventricular substitute. Follow-up of recent Ross cases where a human pulmonary artery homograft was initially used to reconstruct the right ventricular outflow tract has shown a remarkable freedom from failure (94% at 5 years, 83% at 20 years). Although pioneered solely by Mr. Donald Ross of London, England, surgeons in many other centers throughout the world are now able to reproduce similar excellent results with pulmonary autotransplantation. Reoperation rates for failure of the autotransplant and/or the right ventricular homograft are neglible in most centers (less than 10% at 10 years).

There is growing evidence that a pulmonary autograft properly implanted into the aortic position will continue functioning indefinately. The tissues of the patients own pulmonary valve have not shown a tendency to calcifying, degenerate, perforate, or develop leakage over time even when transplanted into the higher pressure aorta. There have been a few reports of late occurring dilation of the aortic root causing central leakage of the autotransplanted valve. However, this problem occurred before the technique of total root replacement was widely adopted. It is now known that secondary root dilatation can be prevented by reinforcing the aortic diameter with a cuff of Dacron, Teflon, or native pericardium during implantation of the pulmonary autograft. Post-operative studies now confirm that leakage is present in only 10% of modern cases, and usually will not progress.

Dr. Ronald Elkins from Oklahoma City has reported about 15% of pulmonary homografts (used to reconstitute the right ventricular donor site) will contract or shrink within 6 months of implantation. However, this does not appear to make a major difference in function of the homograft. In contrast, aortic tissue used in the right ventricular repair is not nearly so effective. For example, when a human cadaver aorta (i.e. homograft is used to replace the pulmonary valve, the freedom from degeneration in the cadaver tissues is only 74% at 5 years. In contrast, when the right ventricular reconstruction is done with a pulmonary homograft, the freedom from degeneration is 94% at 5 years and still an admirable 83% at 18 years[Ross 1996]. This new data clearly points out that the long term fate of patients is partly determined by the conduit used for the right ventricular reconstruction. As the superiority of the pulmonary homograft for this purpose has been realized, the overall results of the Ross procedure have improved.

Dr. James Oury of St. Patricks Hospital in Missoula Montana is actively maintaining a registry of all reported Ross operations in the modern era. As of April, 1996, The International Ross Registry included data on 1,976 Ross procedures performed by 126 surgeons throughout the world. The average age of the patient population at the time of surgery was 28.7 years. Seventy-three percent of the patients were males. Over half of these cases were operated for congenital aortic valve disease, such as bicuspid aortic stenosis. Over 30% of these patients had undergone heart surgery at some time before the Ross procedure was performed. The combined operative mortality rate for the nearly 2,000 patients in the Registry (including small babies) was 5.4%. However, in stable adult patients undergoing elective operations, the mortality rate is now below 1%[Ross 1991]. The incidence of post-operative bleeding requiring reoperation was an admirable 0.9%. In the University of Indiana experience, the average length of hospital stay was only 5.9 days for all patients, including patients with previous heart surgery and children with complex anomalies. Only 24% of patients required any blood transfusions before hospital discharge. The symptoms or findings of aortic valve disease were relieved or greatly improved in all patients. Follow-up echocardiograms revealed only trivial or mild valve leakage in the vast majority.

In the "classic" era of the Ross procedure (prior to 1986), there were some late failures. Of these, 73% initially had the pulmonary valve implanted using the subcoronary ("freehand") technique. Due to this higher rate of surgical failure, this technique has been abandoned by most surgeons. Only 16% of failures occured in patients who had full root replacement with the entire sino-tubular mechanism of the pulmonary valve.

For patients who are candidates for the Ross procedure, there is no better alternative available. Long term survival, freedom from reoperation, stroke, anticoagulation, and the potential for growth of the aortic replacement (in children) are clearly superior to that which is offered by prosthetic valve replacements. For more comparisons, you might want to review the sections on Pros and Cons and Patient Selection for the Ross procedure. In addition, the other topics presented on this Learning Center symposium about the Ross procedure are available through the links below.

1. Ross D, Jackson M, Davies J. J Cardiac Surg 6: 529-33, 1991.

2. Mr. Donald Ross. 1996 Personal Communication at the Indiana Ross Symposium. May 12, 1996.

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

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