Ross Procedure: Is It Right for Me?
Medically reviewed by Jeffrey S. Lander, MDMedically reviewed by Jeffrey S. Lander, MDThe Ross procedure is a type of heart surgery that is used to replace a damaged aortic valve. The aortic valve allows blood to move from your heart into your aorta. Your aorta carries blood from your heart to the rest of your body.The Ross procedure removes the diseased aortic valve and replaces it with your own pulmonary valve. A donor pulmonary valve replaces your own.This procedure works best for active, healthy people under age 60. It may also be an option for teens, children, and some babies under 1 year old.This article describes the Ross procedure and how it compares to other treatments. It explains who qualifies and what to expect as you recover.
Photo composite by Michela Buttignol for Verywell Health; Getty Images
Ross Procedure vs. Other Heart SurgeriesThe Ross procedure is just one surgical option for aortic valve replacement. Replacement is necessary when repairing a damaged aortic valve will not restore the valve to its normal function. Aortic valve replacement surgery can be performed using traditional open techniques or minimally invasive methods.There are also several options regarding the type of valves used in aortic valve replacement surgery. These options include:Mechanical valves: These valves are manufactured from long-lasting mechanical parts, which are intended to last a lifetime. Most people with mechanical valve replacements have to take an anticoagulant (blood thinner) medication such as Jantoven (warfarin) for the rest of their lives. This reduces the risk of clots forming and becoming lodged in the valve flaps or hinges and causing a malfunction.Biological valves: These valves, also called tissue or bioprosthetic valves, are made from pig tissue (porcine), cow tissue pericardial (bovine), or pericardial tissue from other species. They may also contain some artificial components to provide additional support and allow the valve to be sewn into place. While these valves don't last as long as mechanical valves, they do not require the lifetime use of anticoagulants.Homograft: Also called an allograft, this type of aortic or pulmonic valve has been removed from a donated heart. The replacement valve is preserved with antibiotics and frozen until needed. Homografts are ideal valves for aortic valve replacement, especially when the aortic root is diseased or endocarditis (infection) is present. Taking anticoagulants is not necessary.
Conditions TreatedThe Ross procedure and other aortic valve replacement surgeries are used when a damaged or diseased aortic valve can't be repaired.Without replacement, aortic diseases force your heart to pump harder to provide the blood that the rest of your body needs to function normally. Replacing a damaged aortic valve restores function and reduces the risk of heart failure and other types of heart disease.Aortic valve replacement surgeries are used to treat dysfunctional aortic valves that occur due to the following conditions, which may occur as congenital (present at birth) or acquired problems:Aortic stenosis: This condition involves a narrowing of the opening of the aortic valve. This forces your heart to work harder than usual to pump blood through a smaller opening, with less blood than normal reaching your aorta.Aortic insufficiency or regurgitation: This condition interferes with the normal closure of the valve. As a result, the blood leaks back, or regurgitates, back into your heart. This forces your heart to work harder to pump out the blood your body needs to function normally.Aortic stenosis and aortic insufficiency can affect your aortic valve at the same time.Surgical TechniquesSurgical techniques for aortic valve replacement include the following:Open Heart SurgeryOpen heart surgery involves making an incision through the chest. Your breastbone is divided so your surgeon can see and gain direct access to your heart and aorta.Two types of open heart surgery for aortic valve replacement include:Traditional aortic valve surgery: This technique involves a 6- to 8-inch incision down the center of the breastbone. The breastbone is partially or completely divided to allow access to the heart.Ross procedure: This technique involves breaking the breastbone and using your own pulmonary valve to replace a diseased aortic valve. A valve from a donor heart is used to replace your own pulmonary valve.Minimally Invasive SurgeryMinimally invasive surgery is a type of surgery that involves smaller incisions and shorter recovery times. These procedures are also known as laparoscopic or keyhole procedures.Two types of minimally invasive surgery for aortic valve replacement include:Minimally invasive aortic valve surgery: This surgery is performed through small 2- to 4-inch incisions. It reduces blood loss, trauma, and the length of your hospital stay.TAVR (transcatheter aortic valve replacement): Also known as transcatheter aortic valve implantation (TAVI), this procedure involves the insertion of a catheter (a thin tube) within a blood vessel, often your femoral artery near your groin. The catheter is threaded up to your heart so a new aortic valve can be passed through the catheter and put into place to replace the damaged one.Surgery Success and RisksTraditional Aortic Valve SurgerySuccess: Likely to last a lifetime when used with a mechanical valve and delivers survival outcomes comparable to the general healthy populationRisks: Risk of blood-clotting that must be managed by lifelong anticoagulation medicine and infectionRoss ProcedureSuccess: Restores normal life expectancy and quality of life, no anticoagulation medicine needed, low risk of infection, optimal blood flow, and long-term freedom from reoperationRisks: Surgical complexity and may require reoperationMinimally Invasive Aortic SurgerySuccess: No lifelong anticoagulation medicine when used with a tissue valve, and less traumatic smaller cuts reduce risks of infectionRisks: Valve wearing out and requiring reoperation in younger patients and not suitable for patients with intolerable/allergy to products of bovine/porcine originTAVR/TAVISuccess: Lower risk of infection, less trauma to your chest and heart muscle, less time hospitalized, and decreased recovery timeRisks: Valve leaks, need for pacemaker, kidney damage from the contrast dye used for imaging, vessel damage, and the use of biological valves increasing the need for reoperation, especially in younger adults Comparing Heart Surgery OptionsThere is no one-size-fits-all technique for aortic valve replacement. Your surgeon determines the treatment most appropriate for your condition based on the following factors:Your age, general health, and medical historyPrevious heart treatments or valve replacementsThe severity of your diseaseYour signs and symptomsYour tolerance for specific procedures, medications, and/or therapiesYour expectations for the course of the diseaseYour lifestyleYour preferences
Ross Procedure Step-by-Step: What Happens?The Ross procedure involves removing a diseased aortic valve and replacing it with your own pulmonary valve. Relocating the pulmonary valve is possible because it is anatomically similar to an aortic valve.As the relocated pulmonary valve adjusts to its new position, it becomes thicker and stronger. Within a few months, it functions like a healthy aortic valve.The space left from your relocated pulmonary valve is filled with a pulmonary valve from a donor heart. Since the pulmonary valve doesn't have to generate as much force to push blood to the lungs, the demands can usually be met with a replacement valve.A Ross procedure can take six to eight hours. It involves the following steps:You are sedated with general anesthesia so you won't feel pain during the procedure.You are placed on a cardiopulmonary (heart-lung) bypass machine, which works as your heart and lungs during the procedure. This makes it possible to safely stop your heart.Your surgeon performs a sternotomy to access your pulmonary and aortic valves. This involves making an incision down your chest and separating your sternum (breastbone).Your pulmonary valve is inspected to ensure it is healthy enough to be removed and function as a replacement aortic valve.Your surgeon removes your defective aortic valve.Your surgeon removes your pulmonary valve and attaches it in the position previously occupied by your defective aortic valve.Your surgeon attaches a pulmonary valve from a human donor heart into the space left open by your own pulmonary valve.You are slowly removed from the cardiopulmonary bypass machine as your heart begins pumping on its own.The aortic and pulmonary valves are tested to ensure they function properly.Your breastbone is replaced and secured with wires so it can heal.Your incisions are closed with stitches and covered with a surgical dressing.When the procedure is complete, you are moved to the coronary/cardiac care unit (CCU) for recovery.A breathing tube may remain in place for four to five hours after surgery. It is removed when you can breathe normally without assistance.How to Qualify for the Ross ProcedureYour cardiac surgeon will carefully evaluate your condition to determine whether you qualify for the Ross procedure. While you may meet the criteria for the Ross procedure, factors such as the type of valvular dysfunction present, the presence of other medical conditions, and lifestyle considerations are carefully weighed.Generally, the Ross procedure is reserved for people with aortic valve disease, such as aortic stenosis or aortic insufficiency, who meet the following criteria:Age 60 or underLack of other major medical problems or conditions, such as kidney, liver, or lung diseaseA healthy pulmonary valve that can be used to replace the diseased aortic valvePeople in the following groups who meet the procedure criteria are likely to experience the most benefits of a Ross procedure:People who are physically activeWomen planning to have childrenPeople with a failed valve from a previous replacementPeople with a very small aortic valve that needs replacement, typically women and childrenPeople who have a contraindication to anticoagulation medicationPeople who want to avoid additional open-heart surgeriesThe Ross procedure is not an option for people who have the following conditions:Extreme age (older than 70 years)Connective tissue disorders (Marfan syndrome, Loeys-Dietz syndrome)Pulmonary valve diseaseAutoimmune disorders (such as rheumatoid arthritis, systemic lupus erythematosus)Significant kidney disease, liver disease, or lung diseaseSignificant coronary artery disease or mitral valve disease Finding a Specialized Care Team/SurgeonDespite its successful outcomes, few surgeons use the procedure due to its complexity. It represents just 0.09% of all aortic valve replacements performed in the United States. Talk to your cardiologist to find a surgeon that specializes in the Ross procedure.You can also consult the directory of Ross procedure surgeons to locate a Ross procedure surgeon in your area.
Ross Procedure RecoveryYour Ross procedure recovery will vary based on your surgical outcomes and other factors such as your age and general health. Your surgeon will provide instructions and guidelines specific to your condition and recovery plan.It is common to spend the first two to three days after surgery in a CCU. You will likely stay an additional few days in a medical/surgical unit for a total of about five to seven days or more in the hospital after your surgery.Short-TermRecovery from the Ross procedure can take four to eight weeks or longer, depending on your condition. Your breastbone usually heals in about six to eight weeks, but it may take two to three months for you to regain your normal strength and feel like yourself.Before you leave the hospital, your care team will provide detailed instructions regarding diet, wound care, and guidelines for resuming normal activities and routines.A typical short-term care plan involves the following instructions:Consume a diet rich in fruits, vegetables, whole grains, nuts, and seeds, while reducing the amount of salt and sweets in your diet.Enroll in a cardiac rehabilitation program, which involves a dedicated program to support you as you heal, recover, and return to your everyday routines.Take medications as directed.Wait six weeks to resume driving to allow your concentration, reflex time, and eyesight to return to normal.Abstain from sex for at least three weeks.Wait at least six weeks to return to work. If your job involves heavy lifting, you may have to wait up to three months to resume your normal responsibilities.Wait at least one week to resume light activities around your home while delegating heavier tasks to others until you are fully recovered.Exercise daily, beginning with short and simple walks and gradually increasing the length and intensity of your activities.Your surgeon may prescribe one or more of the following medications to help you remain healthy during your recovery and prevent complications:Pain medication, usually prescribed in decreasing amounts as the pain subsides and you regain strengthDiuretics (drugs that lower blood pressure by reducing the fluid in your blood that has to be pumped by your heart)Beta-blockers (drugs to keep your blood pressure low while your pulmonary valve adjusts to its new function as an aortic valve)Angiotensin converting enzyme (ACE) inhibitors to provide additional control of blood pressure or if your condition involved a severe valve regurgitation with a dilated left ventricleAnticoagulants (blood thinners) are not typically prescribed after a Ross procedure. In some cases, aspirin may be prescribed.Long-Term Care and MonitoringResearch indicates that the Ross procedure can be an excellent option for aortic valve replacement for certain patient populations. It provides superior long-term survival, with those treated having survival rates that match the normal population. It also promotes excellent blood flow and has the potential for growth when used in children, including neonates and infants.Long-term care and monitoring after a Ross procedure typically involves the following:Monitor your blood pressure daily to keep the systolic pressure (the top number of a blood pressure measurement) under 110 during the first year after your surgery.Maintain a schedule of visits to your cardiologist every few months or as advised during the first year after your Ross procedure.Maintain a schedule of annual visits to your cardiologist for the rest of your life to ensure your heart valves are working properly and identify the need for replacement if it occurs.You can support your new heart valves by living a heart-healthy lifestyle. The American Heart Association (AHA) advises that people with heart disease follow what the AHA calls "Life's Simple 7," to support long-term cardiovascular health:Stop smokingEat betterGet activeLose weightManage blood pressureControl cholesterolReduce blood sugar
Learn More: New Mechanical Heart Valve Design Has Potential to Reduce Need for Blood Thinners
SummaryThe Ross procedure is a treatment option to replace an impaired aortic valve. When the valve is damaged, it creates extra stress on your heart as it works harder to bring blood to the rest of your body. When a damaged aorta can't be repaired, a new aortic valve can restore normal function.The Ross procedure removes your damaged aortic valve and replaces it with your own pulmonary valve. Using your natural tissue provides a stable substitute without the risk of rejection. A pulmonary valve from a donor heart is used to replace your pulmonary valve.The Ross procedure offers a unique aortic valve replacement choice. It provides those treated with a life expectancy close to people with healthy hearts. Other benefits include long-term valve life without the need for blood thinners.Contact your healthcare provider or cardiologist to discuss whether the Ross procedure is right for you. They can help you find a trained Ross surgeon if you decide to pursue this treatment. Read the original article on Verywell Health.
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