Aortic Valve Ross Operation

Brown KN, Kanmanthareddy A.

Introduction
The Ross procedure, also known as the switch procedure, is a cardiac surgery procedure in which the diseased aortic valve is replaced with
the patient's own pulmonary valve, followed by replacement of the pulmonary valve with a pulmonary homograft. In some children and
infants, sometimes and aortic valve replacement is necessary for a variety of reasons. However, inserting a prosthetic valve is not a good
option; firstly there are no small-sized aortic valves available and secondly, since the child will grow in size, the prosthetic valve will remain
the same size and lead to symptoms of left ventricular outflow tract obstruction. In addition, there are some people who do not want to take
oral anticoagulant medications for life and hence a Ross procedure would be ideal for them. Unlike a prosthetic valve, the ross procedure
has excellent hemodynamics and the risk of embolic complications is almost zero. Finally, as the child grows, so does the valve.
Unfortunately, it is now realized that the Ross procedure also has limitations; the pulmonary homograft will develop regurgitation or
stenosis after 15-20 years, necessitating another procedure.

The Ross procedure was first developed in the late 1960s and has been performed many times since then. It remains to be the only operation
that allows for an aortic valve replacement with a living valve substitute. [1] Over the years, the original procedure has been gradually
modified to perfect the surgical outcome, but the main principles outlining the procedure remain. This chapter will discuss in detail the
anatomy of the aortic valve, indications, contraindications, equipment, personnel, preparation, technique, complications, and clinical
significance of the Ross procedure. 

Anatomy and Physiology

Four chambers comprise the heart. The superior two chambers are the right and left atria while the bottom two chambers are named the
right and left ventricles. Atrioventricular valves separate the atria and ventricles. There are two semilunar valves: the pulmonic valve
separates the right ventricle and the pulmonary artery, while the aortic valve separates the left ventricle and the aorta. The right side of the
heart pumps blood at a lower pressure into the pulmonary vasculature to be oxygenated. The left side of the heart pumps blood in the
systemic circulation at a much higher pressure. Therefore the valves on the left side of the heart are subject to higher pressures.

During the Ross procedure, it is critical to know the anatomy of the left main coronary artery and its take-off. In addition, the surgeon should
know the course of the left coronary artery, its proximal septal branches and their relationship to the aortic root and the right ventricular
outflow tract. In addition, when harvesting the pulmonary autograft the surgeon should have an appreciation of the subpulmonary conal
musculature to facilitate the dissection. Finally, if the left ventricular outflow tract needs enlargement (Ross Konno procedure) the surgeon
must be familiar with the location of the conduction system.

Indications
Indications for the Ross procedure include [2][3]:

1. Aortic valve disease in children with congenital aortic stenosis (most common indication)
2. Females of childbearing age wanting to bear children in the future with bicuspid aortic valve and small aortic annulus
3. Some variations of left ventricular outflow obstructive disease
4. Native or prosthetic valve endocarditis depending on the extent of disease
5. Some forms of adult aortic regurgitation with a dilated aorta 
6. Severe forms of aortic valve disease not amenable to repair

Contraindications
Absolute contraindications [2]:

Marfan syndrome
Pulmonary valve disease
Immune disorders like lupus
Advanced three-vessel coronary artery disease
Significant mitral valve disease

Relative contraindication: (due to a higher risk of autograft dysfunction)

Rheumatic valve disease 

Dysplastic dilated aortic root

Equipment
Prior to the procedure, an echo should assess the aortic valve, the left ventricular outflow tract obstruction, and any other cardiac
abnormality. The pulmonary valve should also be assessed for stenosis or regurgitation. Echocardiography also allows for sizing the aortic
and pulmonary annulus. If the aortic annulus is smaller than the pulmonary annulus by 2-3 mm, the surgeon may be required to perform an
aortic root enlargement procedure.

The Ross procedure is performed via a median sternotomy under cardiopulmonary bypass.

The postoperative course is the same as for any other open-heart surgery patients. Patients are usually weaned off the ventilator the same
night and extubated in the morning.

Personnel
A trained cardiothoracic surgeon, anesthesiologist, cardiologist, imaging specialist, surgical assistants/nursing, scrub/operating room
technicians, and ancillary staff are recommended for a successful, safe procedure.

Preparation
The primary goal in preparation for the Ross procedure along with any other surgical procedure is to achieve sterility. This means the chest
needs to be shaved and sterilized, followed by placement of sterile drapes to allow access to the surgical field only once the opening of the
chest during the procedure has occurred. The Ross procedure is conducted under general anesthesia, and therefore pre-anesthetic
evaluation and intubation for maintaining airway and sedation are utilized. Depending on the center and the operator, pre-operative and
perioperative transesophageal echo may be performed.

Technique
Following a median sternotomy, the Ross procedure begins with standard exposure of the heart and the aorta followed by establishing
cardioplegia and initiation of cardiopulmonary bypass. The ascending aorta is opened transversely about a centimeter above the origin of
the right coronary artery (RCA). The aorta is opened and the aortic valve is inspected. In some cases, the valve may be repaired. If repair is
not possible, then the pulmonary artery is opened and the pulmonary valve is inspected to ensure that it has normal anatomy. If the decision
is made to proceed with the Ross procedure, the aorta is separated from the aorta, the diseased aortic valve is excised and the coronary
buttons are prepared. Next, the pulmonary valve is excised.

If no abnormalities are present, the main pulmonary artery (PA) is opened transversely proximal to the bifurcation. The pulmonary valve
(PV) is then itself inspected for anomalies. Again if no abnormalities exist, then the valve replacement is performed using the full root
approach. The full root approach is most commonly used about 90% of the time because it has the lowest risk of pulmonary autograft
failure.[2]  In rare circumstances, depending on the anatomy, another approach may be a better choice, such as the sub-coronary, sub-
coronary with retained noncoronary sinus, or cylinder approaches.

In this article, we describe the full root approach because it is the most commonly used method. The full root approach is begun by moving
the root out of the surgical plane and pushed upwards. The posterior PA root is then cut to the muscle to visualize the right ventricular
outflow tract (RVOT) through the incision. Next, the PA is separated from the aorta, and a clamp is then used to designate the most proximal
area to the pulmonary valve. It is vital that the surgeon be aware of the left anterior descending coronary artery and the first septal while
dissecting on the lateral side.

In the next step, an opening into the RVOT is created followed by dividing the anterior right ventricle and scoring the posterior muscle of the
right ventricle partially. Following this, the pulmonary artery root is excised and separated. Next, removal of the aortic valve and root occurs
after carefully cutting out the ostia with buttons from the native aorta.

Once the pulmonary valve is removed, it is sized and prepared for implantation into the aortic root.

Now the pulmonic autograft is anastomosed to the LVOT followed by reimplantation of the right and the left coronary arteries on to the
autograft, followed by proximal anastomosis of the pulmonic autograft, and hemostasis is secured.

A cryopreserved pulmonary homograft is then trimmed as needed and implanted into the pulmonary root. After weaning from
cardiopulmonary bypass, a transesophageal echocardiogram is done to assess the function of the autograft and the homograft. [4]

Prior to discharge, an echocardiogram is repeated to ensure that both the aortic and pulmonary valves are functioning normally. Patients
are then examined every 4-6 weeks with echos. It is important to cover patients with antibiotics prior to any procedure.

Complications
Potential complications with the Ross procedure include[5]:

Aortic insufficiency
Right ventricular outlet obstruction
Aortic autograft dilatation
 Pulmonary allograft stenosis
Cerebrovascular event
Myocardial infarction/ischemia
Hemorrhage
Respiratory distress
Drug reactions
Blood reactions
Arrhythmias
Infection
Death

Complications related to surgery occur in 3-5% of patients with early mortality of 1-3%. In experienced centers, the mortality rates are
negligible. Long term survival of 80-90 % have been reported at ten years and 70-80% at 20 years.

Early autograft failure is rare but does occur within the first 6 months. In most cases, the cause is technical problems such as leaflet injury or
distortion that is caused during the valve harvesting. The pulmonary homograft in most series lasts about 15-20 years and then develops
regurgitation or stenosis due to calcific degeneration. However, today the percutaneous placement of a pulmonary valve is being performed
instead of open-heart surgery.

There is no doubt that the Ross procedure is superior to the prosthetic valves. Unfortunately, recent data show that in some patients there is
increasing enlargement of the new aortic root following the Ross procedure leading to aortic regurgitation, especially when there was a
mismatch of the aortic and pulmonary roots at the time of the initial surgery.

Patients who undergo the Ross procedure do not require anticoagulation and have minimal restrictions on their lifestyle. They are also able
to participate in exercise programs without limitations. However, the Ross procedure is demanding and life long monitoring of the patients
is required. Reoperations have been infrequent and with the availability of percutaneous valve implantation techniques, the morbidity of
REDO open heart surgery will be avoided.

Clinical Signi cance

Multiple studies have shown that there is a durable, long-term clinical success from this procedure with an extremely low mortality rate.
Because this procedure uses biological valves, it obviates the need for oral anticoagulation which would have otherwise been necessary for
this particular group of patients because they would have needed mechanical valves. [6] The Ross procedure also eliminates the need for
aortic valve replacement for up to as much as 20 years. This is probably due to two factors. One being that the autographed pulmonary valve
in the place of the aortic valve has the ability to grow as the patient grows and the second being that there are lower pressures in the right
side of heart creating for less stress on the pulmonary valve replacement and subsequently this leads to a reduced failure rate. Overall, this
procedure is an excellent option for children and youth to improve survival. It remains to be the only operation that allows for an aortic
valve replacement with a living valve substitute.

Enhancing Healthcare Team Outcomes

The Ross procedure is major cardiovascular surgery, therefore it is imperative to utilize an interprofessional team working across disciplines
to provide care for these patients.

The enthusiasm for this procedure has varied over the last several decades with studies demonstrating lower mortality, bleeding,
thromboembolism, endocarditis compared to mechanical valve replacement but with the need for higher risk of reintervention of the auto
and allograft valves because of structural deterioration. Further, operator experience and expertise are essential for achieving excellent
clinical outcomes, and therefore this procedure should be performed at high volume centers of excellence. To achieve the best outcomes, a
team of cardiac surgeons, cardiologists, cardiac nursing specialists, and specialty-trained cardiac pharmacists must work together to
coordinate evaluation, surgical care, and long-term postoperative follow-up. The nurses must assist with monitoring the patient post-
operatively and long-term to identify potential complications early. The nurses must also assist the medical team in educating the patient
and the family in regards to expected outcomes and warning signs to watch for as well. The cardiac pharmacist should make sure there is no
potential for drug-drug interactions and medications are appropriately dosed by the surgical team leader in the perioperative period.
Communicating potential risks to the medical team, the clinical pharmacist can help prevent adverse outcomes. Only a collaborative
interprofessional team approach will result in good long-term outcomes in patients undergoing the Ross procedure. [Level 5]

The American College of Cardiology/American Heart Association currently recommends Ross as a Class IIb while the Society for Thoracic
Surgeons recommends this as a class III indication in patients needing aortic valve surgery. Because of the above recommendations, the
utilization of the Ross procedure has been in decline. The emergence of transcatheter valve replacements for degenerating bioprosthetic
valves which in the case of the Ross procedure are the auto and allografts are easily replaceable without the need for open-heart surgery. In
the future, this may provide a new lease of life for the Ross procedure. [7][8][9][10]

Continuing Education / Review Questions

 Earn continuing education credits (CME/CE) on this topic.
Access board review questions for this topic.
Comment on this article.

Figure
Aortic Valve. By Anatomist90 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17215093

Figure
Aortic Valve. Valveguru [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Figure
Recommendations for aortic valve replacement. Contributed by Sai Harika, MBBS

References
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2. Morita K, Kurosawa H. [Indications for and clinical outcome of the Ross procedure: a review]. Nihon Geka Gakkai Zasshi. 2001
Apr;102(4):330-6. [PubMed: 11344686]
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to Repair. Front Surg. 2018;5:18. [PMC free article: PMC5850822] [PubMed: 29564333]
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[PubMed: 11678251]
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Publication Details

Author Information

Authors

Kristen N. Brown1; Arun Kanmanthareddy2.

A liations

1
Augusta University
2
University of Texas Houston

Publication History

Last Update: July 31, 2020.

Copyright

Copyright © 2020, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation,
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Publisher

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NLM Citation

Brown KN, Kanmanthareddy A. Aortic Valve Ross Operation. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.