Ross procedure

Overview

The Ross procedure, sometimes called the pulmonary autograft procedure or Ross heart procedure, is a type of aortic valve replacement. The Ross procedure replaces the diseased aortic valve with your pulmonary valve. The moved pulmonary valve is called an autograft.

Your pulmonary valve is then replaced with a donated human valve, called a pulmonary homograft. No artificial valves are used in the Ross procedure.

The use of living and donated tissue in the Ross procedure may help reduce some long-term risks associated with artificial heart valves. Artificial valves may be made from materials such as metal, carbon or animal tissue.

Types

The Ross procedure can be done in different ways. The type of procedure depends on what heart condition needs treatment. One type is the Ross-Konno procedure. This is a Ross procedure, but the left ventricular outflow tract (LVOT) is enlarged. This tract is the pathway that carries blood from the heart's main pumping chamber through the aortic valve. The Ross-Konno procedure is mainly used in children with severe narrowing of the LVOT.

Why it's done

The Ross procedure may be considered when a diseased aortic valve cannot be repaired and heart valve surgery is needed. Since your own pulmonary valve is living tissue, it can adapt. This helps it to work in the aortic position, where blood pressure is higher. It allows natural blood flow. A donated pulmonary valve can work well in the pulmonary position, where blood pressure is lower.

It may be an option for people who:

• Have severe aortic stenosis, aortic regurgitation or both.
• Are younger and need a valve that can work well for many years.
• Want to avoid lifelong blood-thinning medicine.

The Ross procedure may be considered in children, teenagers and carefully selected adults. Age alone does not determine whether the procedure is right for you. A healthy pulmonary valve and the ability to tolerate a complex open-heart operation are important factors.

People with a bicuspid aortic valve also may be candidates for the Ross procedure. The surgeon considers:

• Size and shape of the ascending aorta and the aortic root. The ascending aorta is the part of the aorta that carries blood from the heart toward the upper body. The aortic root is the part of the aorta closest to the heart.
• Valve opening.
• Whether the aortic valve leaks.
• Blood pressure control.

The surgeon also considers other factors that can affect how long the autograft lasts.

Some people may not be good candidates if they have:

• Certain inherited conditions that affect the aorta.
• Significant pulmonary valve disease.
• Autoimmune conditions.
• High surgical risk.

How the Ross procedure compares with other valve replacement options

Other surgical options are available for aortic valve replacement. Here is how some of them compare with the Ross procedure.

Compared with a mechanical aortic valve

The Ross procedure usually avoids lifelong blood-thinning medicine and the ongoing risk of bleeding and blood clots. Mechanical valves, however, generally lower the risk that another valve operation is needed in the future. The Ross procedure has shown lower long-term risks of stroke and major bleeding in comparative studies of young adults.

Compared with a tissue valve, also called a bioprosthetic valve

The Ross procedure has shown better long-term survival and fewer valve-related procedures in selected younger and middle-aged adults. This does not mean the Ross procedure is the right choice for every person.

Compared with the Ozaki procedure, which rebuilds the aortic valve leaflets instead of moving the pulmonary valve

The Ross procedure may lower the chance of another aortic valve operation compared with the Ozaki procedure. But the pulmonary homograft used in the Ross procedure may need another procedure in the future. Only a small number of studies have directly compared the two procedures. Most of those studies have involved children. More research is needed to understand which procedure may be a better choice for each person.

Risks

The Ross procedure is major open-heart surgery. Risks of surgery depend on age, overall health, heart structure, previous heart procedures and other factors. Serious risks and complications can happen soon after surgery or over time.

Risks soon after surgery include:

• Bleeding. Bleeding can happen during or after surgery. If bleeding is severe, a blood transfusion or another operation may be needed.
• Infection. An infection can develop after surgery. If the infection affects a heart valve, it is called endocarditis.
• Heart rhythm changes. The heart may beat too fast, too slowly or irregularly after surgery. Some people may need a permanent pacemaker to help control their heartbeat.
• Stroke, heart attack or organ injury. These complications are not common, but they can be serious. They can happen if blood flow to the brain, heart or other organs is affected during or after surgery.

Risks over time include:

• The autograft may stretch or leak. The pulmonary valve, once it is moved to the aortic position, is called the autograft. Because the pressure is higher in this position, the autograft can stretch over time. This can enlarge the part of the aorta closest to the heart, known as the aortic root, and cause the valve to leak.
• Narrowing or leaking of the pulmonary homograft. The donor valve placed where the pulmonary valve once was is called a pulmonary homograft. Over time, this valve can wear out, become narrowed or begin to leak.
• Reduced blood flow through a coronary artery. The coronary arteries are the blood vessels that supply blood to the heart muscle. During the operation, these arteries are moved and reattached. Although rare, a change in a coronary artery after surgery can limit blood flow to the heart muscle.

How you prepare

Before surgery, your healthcare team reviews your medical history, medicines and previous heart procedures. Tests often include an echocardiogram to check the heart and valves. Other tests look at the aorta and coronary arteries. These tests may include an electrocardiogram (ECG), chest X-ray, blood tests and computerized tomography (CT).

Your care team tells you when to stop eating and drinking before surgery. If you smoke, your care team may tell you to stop before surgery. Smoking can increase the risk of complications after surgery. Tell your care team about all medicines, vitamins and supplements you take. You may need to stop taking certain medicines before surgery, including some blood-thinning medicines. Do not stop taking a medicine unless your healthcare professional tells you to.

Your care team gives you specific instructions about preparing for the operation.

Plan for a hospital stay and for help at home as needed during the early part of your recovery.

What you can expect

Before the procedure

You receive a general anesthetic, so you are asleep and do not feel pain during surgery. Your care team places monitoring equipment to check your heart rate, blood pressure, breathing and other vital signs. A breathing tube helps you breathe during surgery and shortly afterward.

During the procedure

The Ross procedure is usually done through an incision in the middle of the chest. The surgeon opens the breastbone to reach the heart. How long the Ross procedure takes differs for each person.

This procedure generally takes longer than standard surgical aortic valve replacement because the surgeon reconstructs both the aortic and pulmonary valve areas. The time needed depends on heart anatomy, surgical technique and whether other procedures are needed.

The surgical team connects you to a heart-lung bypass machine. This machine temporarily does the work of your heart and lungs while the surgeon operates.

The surgeon checks the pulmonary valve to make sure it can be used before the diseased aortic valve is removed. The pulmonary valve and nearby tissue are removed to and used as the pulmonary autograft.

The pulmonary autograft is placed where the diseased aortic valve was removed. The coronary arteries, which supply blood to the heart muscle, are reattached to the autograft. A pulmonary homograft from a donor replaces the pulmonary valve that was moved.

The surgical team checks the valves and takes you off the heart-lung machine. Your heart takes over pumping blood again. The breastbone is put back together so it can heal. The chest incision is then closed.

If a Ross-Konno procedure is needed, the surgeon also enlarges the narrowed pathway from the left ventricular outflow tract (LVOT) to the aorta.

After the procedure

After surgery, you go to an intensive care unit (ICU). There you are closely monitored. The breathing tube is usually removed within hours after surgery when you can breathe well enough without it. Chest tubes drain blood and other fluid from around the heart and are removed as you recover.

Your care team monitors your heart rate, blood pressure, breathing and other vital signs. Medicines are used to control pain and may be used to prevent blood clots or heart rhythm issues.

How long you stay in the hospital depends on your heart condition and the type of surgery you had. Your time in the intensive care unit also depends on the type of surgery and how your recovery is going.

Recovery

Recovery is different for each person. After open-heart surgery, it may take 4 to 6 weeks before you start feeling better. Tiredness and discomfort in the chest, shoulders or upper back can occur during recovery.

Your care team tells you when it is safe to return to work, drive, exercise and lift heavier objects. After heart surgery, you are typically instructed to avoid strain on the chest. Do not lift, pull or push anything more than 10 pounds (4.5 kilograms) for about six weeks. For the best recovery, follow all instructions from your care team. Many people are ready for light work within 6 to 12 weeks, but your recovery may be shorter or longer.

Lifelong follow-up with a heart doctor, called a cardiologist, is important. Both the autograft and pulmonary homograft need regular checks. Managing your blood pressure is especially important during the first year after surgery while the autograft adjusts to its new position.

Over time, either the autograft or the pulmonary homograft may need more treatment. Another procedure on one or both valves may be needed. The treatment may use a thin, flexible tube called a catheter. Or another surgery may be needed.

Your care team may recommend cardiac rehabilitation after surgery. Cardiac rehabilitation is a medically supervised program that helps you safely become more active and recover from heart surgery. It may include supervised exercise, heart-healthy education and help managing stress.

Results

Studies of the Ross procedure have found encouraging long-term results in both adults and children. Many people do not need another valve procedure for decades. Results are different for each person and depend on factors such as age, heart anatomy, the reason for surgery and the surgical technique used.

Clinical trials

Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions.