Overview of Ross Procedure for Aortic Valve Replacement
The Ross procedure, sometimes called the switch procedure, is a type of heart surgery. During this operation, the doctor replaces a damaged aortic valve in the patient’s heart with their own pulmonary valve. They then replace the pulmonary valve with a donor’s pulmonary valve, known as a pulmonary homograft. This procedure might be necessary for some children and infants who need a new aortic valve for various reasons.
The common solution is a prosthetic, or artificial, valve, but this isn’t always the best choice. There might not be a small enough size available, and as the child grows, the valve won’t grow with them. This can lead to a medical condition called left ventricular outflow tract obstruction, which can cause heart-related symptoms. Some individuals also prefer to avoid taking lifelong oral anticoagulant medications—drugs that prevent blood clots—making the Ross procedure a good option for them.
Unlike an artificial valve, the Ross procedure has excellent ‘hemodynamics’, meaning it allows the blood to flow through the heart very effectively. It also has a very low risk of embolic complications — issues related to blood clots.
Moreover, the Ross procedure has the advantage that, as a child grows, the valve grows too. However, it’s also important to note that this procedure has its limitations. After about 15-20 years, the donor pulmonary valve—’pulmonary homograft’—may start to leak (regurgitate) or become narrow (stenosis). This would need another surgery to correct.
This type of operation was first developed in the late 1960s and has been done many times since. It’s the only surgery that allows for aortic valve replacement using a living valve instead of an artificial one. The procedure has been improved over the years to get the best possible outcome, but the basic steps remain the same.
In this simplified version, we’ll walk you through the structure of the aortic valve, when the Ross procedure might be needed, why it might not be suitable for everyone, what equipment is used, who’s involved in the surgery, how the patient is prepared, how the operation is done, what could go wrong, and why the Ross procedure is important.
Anatomy and Physiology of Ross Procedure for Aortic Valve Replacement
The heart is made up of four sections. The top two sections are called the right and left atria, and the bottom two sections are called the right and left ventricles. Valves, which are like doors, separate these sections to control the movement of blood. There are two special valves known as the ‘semilunar valves’. The pulmonic valve is between the right bottom section (ventricle) and the tube carrying blood to the lungs (pulmonary artery). The aortic valve is found between the left bottom section (ventricle) and the main blood vessel in the body (aorta).
The right side of the heart is in charge of pumping blood to the lungs where it gets refreshed with oxygen. The left side of the heart then pumps the newly oxygenated blood throughout the body. As the left side has to work a little harder to do this, the valves on this side are exposed to more pressure.
In certain heart surgeries, like the Ross procedure, knowledge of the heart’s overall structure, and more specifically, how the left main coronary artery is positioned and how it functions, is crucial. This artery supplies blood to the heart muscle. When performing this procedure, the surgeon needs to be aware of the different parts of the heart, how they work, and where they are located, especially around the aortic root and the right outflow tract, which are channels through which blood leaves the heart.
When removing and placing a segment of the pulmonary artery (known as the pulmonary autograft), the surgeon should have a clear understanding of the heart’s muscular structure to facilitate smooth operation. If the surgeon needs to enlarge the left ventricular outflow tract in a procedure known as the Ross Konno procedure, knowledge of exactly where the heart’s electrical system, which regulates heartbeat, is located, is vital.
Why do People Need Ross Procedure for Aortic Valve Replacement
The Ross procedure is a type of heart surgery that might be recommended for several reasons:
1. Children who have a health issue where the valve leading out of the heart to the body (the aortic valve) does not fully open, which is called congenital aortic stenosis. This is actually the most common reason for this procedure.
2. Women who can have children and want to do so in the future, and who are facing a heart condition where the aortic valve has only two leaflets instead of three (bicuspid aortic valve) and the connecting part of the heart is too small (small aortic annulus).
3. Certain types of diseases that block the flow of blood out of the left side of the heart.
4. Infections of a person’s natural or artificial heart valve, depending on how severe the disease is.
5. Some forms of a condition in adults where the aortic valve does not close properly, allowing blood to flow back into the heart (aortic regurgitation), coupled with an enlarged aorta.
6. Severe forms of aortic valve disease that can’t be fixed with other kinds of heart surgeries.
When a Person Should Avoid Ross Procedure for Aortic Valve Replacement
The Ross procedure is a type of heart surgery, but there are certain conditions that may prevent someone from being able to have it. Some conditions mean a person can’t have this surgery at all, these include:
- Marfan syndrome, a genetic disorder that affects the body’s connective tissue.
- Pulmonary valve disease, a condition that affects the valve that controls the flow of blood from the heart to the lungs.
- Immune disorders like lupus, where the body’s immune system attacks its own tissues.
- Severe 3-vessel coronary artery disease, an extreme condition where all three main vessels that supply blood to the heart muscle are blocked.
- Significant mitral valve disease, which is severe damage to the heart valve that regulates blood flow from the upper to the lower chambers of the heart on the left side.
Furthermore, there are certain conditions that don’t prevent the Ross procedure, but they make it more likely to have complications. These include:
- Rheumatic valve disease, an inflammation of the heart valves caused by rheumatic fever.
- A dysplastic dilated aortic root, which means the root of the main blood vessel that carries blood away from the heart (the aorta) is malformed and widened.
Equipment used for Ross Procedure for Aortic Valve Replacement
Before your surgery, an ultrasound of your heart (known as an echocardiogram or ‘echo’) will be performed. This will help the doctors examine the aortic valve, which is a major valve that controls the flow of blood out of your heart. They’ll also check for possible blockages in the outflow tract of the left ventricle (the chamber of the heart that pumps blood out to your body), and any other heart abnormalities. They will also evaluate the pulmonary valve, another important heart valve, for any narrowing (stenosis) or leaking (regurgitation).
The echocardiogram will also be used to measure the size of the openings (or ‘annuli’) of both the aortic and pulmonary valves. If the aortic opening is found to be smaller than the pulmonary opening by about 2-3 millimeters, the surgeon might need to do an operation to enlarge the aortic root. You can watch a video on the movement of the aortic valve for more details.
The Ross procedure, the heart surgery you’ll be undergoing, is carried out through an incision down the middle of the chest (a ‘median sternotomy’) while your body’s blood circulates outside of your body by a method known as ‘cardiopulmonary bypass’. After the operation, the recovery process is similar to what you’d expect after any other open-heart surgery. Generally, patients are eased off the breathing machine (ventilator) the same night after surgery and have the breathing tube (endotracheal tube) removed in the morning.
Who is needed to perform Ross Procedure for Aortic Valve Replacement?
For a safe and effective heart operation, a special team of healthcare professionals is needed. This team includes a specially trained heart surgeon, an anesthesiologist who is responsible for putting you to sleep and monitoring your vital signs during surgery, a heart doctor known as a cardiologist, an imaging specialist who uses equipment like X-rays to get clear images of your heart, surgical nurses and assistants who help out during the operation, scrub technicians who ensure a sterile environment in the operating room, and other staff members who help in various ways. This team works together to ensure the success of your surgery and your safety.
Preparing for Ross Procedure for Aortic Valve Replacement
The main objective before any surgery, including the Ross procedure, is to ensure a sterile environment. That means we need to clean and disinfect the chest area. Once this is done, we cover the patient’s body with clean sheets that have an opening over the chest area. This opening is used to access the chest during surgery. The Ross procedure is performed with the patient under a deep sleep, technically known as general anesthesia. To facilitate this deep sleep and support breathing, certain procedures involving visual examination (pre-anesthetic evaluation) and insertion of a tube to assist in breathing (intubation) are done beforehand. Depending on the medical center and the surgeon, additional monitoring via a specialized ultrasound (transesophageal echo) may also be performed before and during the surgery.
How is Ross Procedure for Aortic Valve Replacement performed
The Ross procedure is a type of heart surgery where the surgeon replaces a diseased aortic valve with the patient’s own pulmonary valve. First, the surgeon will open up the chest (a process called a median sternotomy) to expose the heart and the aorta, which is the main blood vessel leaving the heart. The surgeon then initiates a procedure called cardiopulmonary bypass, which is a technique that temporarily takes over the function of the heart and lungs during surgery. Following this, the surgeon will stop your heart (a process called cardioplegia).
Next, the surgeon makes a cut in the ascending aorta, which is the part of the aorta that rises from the heart. This is done about one centimeter above where the first branch of aorta (the right coronary artery) starts. The surgeon then opens the aorta to examine the aortic valve. In some cases, this valve can be repaired, but if it is too damaged, it must be removed.
If the aortic valve must be removed, the surgeon will then open the pulmonary artery, which carries blood from the heart to the lungs, and inspect it to make sure it is healthy. If everything looks good, the surgeon will proceed with the Ross procedure. This involves removing the diseased aortic valve as well as the healthy pulmonary valve.
The removed pulmonary valve is then transplanted into the position of the previous aortic valve. The pulmonary valve is attached to a structure called the left ventricular outflow tract, which is the passage through which blood leaves the heart’s main pumping chamber. The heart’s arteries are then reattached to the new valve. This process is called anastomosis.
A replacement pulmonary valve, which is donated from a donor and frozen (a process called cryopreservation), is then trimmed and put into the original place of the pulmonary valve. As the last step, the patient is gradually taken off the cardiopulmonary bypass. After the procedure, a special type of ultrasound called a transesophageal echocardiogram is performed to check the function of both the replaced and the donor valves.
Before leaving the hospital, another ultrasound is done to confirm that the replaced aortic and pulmonary valves are working properly. After that, the patient will continue to have ultrasounds every 4-6 weeks. It’s very important for the patient to take preventive antibiotics before any future medical procedures, as there is a risk of infection.
Possible Complications of Ross Procedure for Aortic Valve Replacement
The Ross procedure is a type of heart surgery which has some possible risks involved including problems such as aortic insufficiency, an obstruction in the right ventricular outlet, dilation of the aortic autograft, constriction of the pulmonary allograft, a vary of heart-related issues such as heart attack, arrhythmias and others such as infection, reactions to drugs or blood, and in some cases, death. It’s important to know that roughly 3-5% of patients may experience complications from the surgery, and the early death rate sits between 1-3%. However, in more skilled centers, this death rate tends to be almost nonexistent.
Overall, most people recover successfully from the surgery with a 70-80% survival rate over 20 years and 80-90% over 10 years. Early autograft failures, meaning the body-rejecting transplanted tissue, is fairly rare, usually occurring in the first 6 months due to technical issues during the surgery. Another issue could happen 15-20 years post surgery wherein the new pulmonary valve develops some issues due to calcification. Currently, doctors are fixing this through a less invasive procedure rather than open-heart surgery.
In spite of a few risks, the Ross procedure has been proven to be more effective than using prosthetic valves. Though, it’s been observed that for some patients, the new aortic root can increase in size over time, causing aortic regurgitation especially if there was a size mismatch in the aortic and pulmonary roots during the initial surgery. The good news is that patients who undergo the Ross procedure don’t require anticoagulation and can carry on with their normal lives with minimum restrictions. They can even re-enter their exercise routines without limitations. It’s crucial to understand that the Ross procedure demands regular monitoring, but the need for a second open-heart surgery is rare, thanks to the availability of less invasive heart valve procedures.
What Else Should I Know About Ross Procedure for Aortic Valve Replacement?
Many studies have found that a certain procedure, known as the Ross procedure, is very effective and safe. This procedure uses natural valves instead of mechanical ones which means patients don’t need to take blood thinners, which are usually needed when mechanical valves are used.
The advantage of the Ross procedure is that it skips the need for replacing the heart’s aortic valve for up to 20 years. This is likely due to two main reasons. The first is that the pulmonary valve, which is moved to replace the aortic valve, can grow as the patient grows. The second reason is that the right side of the heart, where the pulmonary valve is placed, usually has lower pressure. This causes less stress on the new valve, reducing the chances of it failing.
This procedure is especially beneficial for children and young people as it can help improve their chances of survival. It’s the only surgery that replaces the aortic valve with a living valve substitute, which is a significant advantage.
