What is the Ross procedure? When is it indicated and what are the advantages?

What is the Ross procedure?
The Ross procedure, or pulmonary autograft procedure, was introduced by Mr Donald Ross in 1967. The operation is performed via median sternotomy on cardiopulmonary bypass. The principle is to replace the diseased aortic valve with the autologous pulmonary valve. The pulmonary autograft is placed in the aortic position as a root replacement with interrupted sutures and the coronary arteries are reimplanted. Great care must be taken during harvesting of the pulmonary root because of the close proximity of the first septal branch of the left anterior descending coronary artery. A homograft (preferably pulmonary) is used to restore continuity between the right ventricular outflow tract and the pulmonary artery. The overall operative risk cited in the current literature is 1.5–7.0%, depending on the patient’s age and surgical indication.

In whom should I consider it?
The Ross procedure is the preferred option for aortic valve replacement in the growing child due to the growth potential of the implanted autograft. It should also be considered in any patient where anticoagulation is completely or relatively contraindicated. Another possible indication is active endocarditis because of its “curative” potential. The likelihood of recurrence of endocarditis and of perivalvar leak is lower in patients after a Ross procedure, compared to mechanical valve replacement.

What are the advantages?
The haemodynamic performance of the autograft valve is superior to mechanical valves, with much lower transvalvar gradients and better regression in ventricular size and hypertrophy in the midterm. Anticoagulation with warfarin (a major contributor to mechanical valve-related morbidity and mortality) is not required after the Ross procedure. More than 90% of all patients are free of any complications (death, degeneration, valve failure, endocarditis) after ten years. However, the subpulmonary homograft may need replacement in the future. The Ross procedure is technically demanding. It is the method of choice for aortic valve replacement in the young, with excellent early postoperative haemodynamic results and good mid-term results. Long term results of the Ross procedure using current techniques are awaited.