The Ross Procedure

11 minutes ago

4 min read

Welcome back, Aortic Hope family! If you or someone you love needs a new aortic valve, you've probably heard about two main choices: a mechanical valve or a tissue valve. But a third option often comes up in our community, especially for younger survivors: the Ross procedure. Today we'll look at how it works, who it's a good fit for, and what trade-offs to consider with your care team.

How the Ross Procedure Works

Your heart has four valves. Two of them sit side by side at the top of the heart: the aortic valve, which sends blood out to the body, and the pulmonary valve, which sends blood to the lungs. The two are similar in size and shape, which makes the Ross possible.

During the operation, the surgeon:

Removes the diseased aortic valve.
Takes out your healthy pulmonary valve and moves it into the aortic position. This moved valve is called the autograft, meaning tissue from your own body.
Reattaches your coronary arteries to the new aortic root.
Puts a donor valve from a human donor in the pulmonary position.

In effect, you get a living valve made of your own tissue in the high-pressure aortic spot, and the donor valve goes in the pulmonary spot, where pressures are much lower and wear is gentler. It's major open-heart surgery, done through the breastbone on the heart-lung machine, and it takes several hours (Cleveland Clinic; American Heart Association).

Who Is It a Good Fit For?

The Ross is usually considered for younger people with aortic valve disease. The American Heart Association describes typical candidates as younger than 50, and Cleveland Clinic suggests people under 60 may benefit. It is often a good fit for:

Active adults who want to exercise without restrictions and avoid the lifelong blood thinners a mechanical valve requires.
Women who hope to become pregnant, since blood thinners make pregnancy more complicated.
Children, because the moved valve can grow with them.
People with a bicuspid aortic valve or other aortic valve disease, as long as their pulmonary valve is healthy.

The Ross is usually not recommended for people with:

Marfan syndrome or other connective tissue disorders.
Autoimmune diseases such as lupus or rheumatoid arthritis.
Advanced coronary artery disease.
A diseased pulmonary valve.

That first point matters for many in our community. If you have Marfan syndrome or another genetic aortic condition, ask your surgeon which of the other root options may suit you better (Cleveland Clinic; American Heart Association).

Weighing the Tradeoffs

Like every valve option, the Ross has real upsides and real downsides. Here's how they line up.

What draws people to the Ross

Usually no lifelong blood thinners. A mechanical valve needs them for life; the Ross usually doesn't.
Fewer strokes and bleeds. In adults, the Ross has been linked to lower rates of stroke and major bleeding than mechanical valve replacement.
An active life. Cleveland Clinic notes that most patients have no restrictions on physical activity afterward.
A living valve. Your own tissue handles the high blood flow of the aortic position well and can grow in children.

What to weigh against it

A bigger operation. You're treating one valve problem by working on two valves, so the surgery is longer and more complex than a standard valve replacement.
More surgery down the road is likely. The donor valve in the pulmonary spot typically needs replacing within 15 to 20 years, so lifelong follow-up matters.
The moved valve can change over time. The aorta around the new valve can widen, and the moved valve can start to leak. Some patients need a catheter procedure or another operation.
Experience counts. Guidelines recommend having the Ross at a Comprehensive Valve Center with a surgeon who does it often, and an experienced surgeon lowers the risk of complications. That may mean traveling for care.

Recovery is similar to other open-heart surgery: a few days in the cardiac ICU, then several months of healing at home (Cleveland Clinic; American Heart Association).

How It Fits With Other Options

The Ross is one of several ways to treat a failing aortic valve or root. If your aortic root is also enlarged, your surgeon may talk with you about a composite valve graft (the Bentall procedure) or a valve-sparing root replacement that keeps your own aortic valve, such as the David or Yacoub procedure. Purab walks through each of these in his post on aortic root surgery. For a quick refresher on the Ross itself, see our 2022 Medical Monday post introducing the Ross procedure.

There is no single best valve for everyone. The right choice depends on your age, your valve and aorta, your other health conditions, your plans for the future, and your surgeon's experience. Bring your questions to your care team, and don't hesitate to ask for a second opinion at a center that offers all of these options.

The Bottom Line

The Ross procedure gives some patients a living aortic valve made from their own tissue, often without lifelong blood thinners. In exchange, it is a bigger operation that involves two valves and usually means more procedures later in life. For the right person at an experienced center, it can be an excellent choice. Talk it through with your surgeon to see if it's a good fit for you.

Thanks for reading, Aortic Hope family!

Take care,

Branden