Patients who need an aortic valve replacement are typically offered either a new mechanical or biological valve. For some patients, there is a third option: the Ross procedure – the only aortic valve replacement option that can restore a patient’s life expectancy to what it would have been before aortic valve disease.
First performed in the 1960s, this advanced, open-heart surgery replaces a patient’s damaged aortic valve with their own pulmonary valve. Using a patient’s own tissue means lifelong blood thinners are unnecessary – a significant benefit for active patients.
But that’s just scratching the surface of this procedure’s advantages. More benefits include:
- Lower risk of needing a future aortic valve replacement
- Good valve hemodynamics, which facilitates an active lifestyle
- Decreased risk of valve infection, transplant rejection, bleeding, or stroke
- Easier blood flow regulation
- No audible clicking sound from a mechanical valve
- Perfect fit for the patient’s heart valve anatomy
- In children and teens, the valve tissue grows naturally with the body
- No restrictions on becoming pregnant, since no blood thinners are required
The Ross procedure is complex and requires a high level of surgical skill. In fact, UT Southwestern’s Department of Cardiovascular and Thoracic Surgery is one of the few medical centers in the U.S. with the advanced team needed to perform it. Our team is recognized as one of the nation's top 20 hospitals for cardiology, heart, and vascular surgery by U.S. News & World Report. Our cross-disciplinary team collaborates closely with Karl Reyes, M.D., the Surgical Director of UTSW’s Adult Congenital Heart Disease Program and a member of the Pediatric Complex Heart Valve Program team at Children's Health.
For people who are good candidates, the Ross procedure can provide a more durable replacement valve that offers more active, healthy years of life. Let’s discuss the basics of this surgery and who can benefit most from the Ross procedure.
How does the Ross procedure work?
The aortic valve is arguably the most important valve in the body. It is the gatekeeper that allows blood to flow from the heart to the body and prevents it from leaking back into the heart between beats.
The Ross procedure is named after British surgeon Dr. Donald Ross, who developed the surgery upon realizing the aortic valve is a mirror image of the pulmonary valve in size and shape. Originally popularized for use in children, the Ross procedure allows for the valve to grow with the child to an extent, decreasing the need for anticoagulant medication and multiple repeated surgeries in childhood.
In adults, the surgery is for patients whose aortic valve function is disrupted by diseases such as aortic stenosis (the valve is narrowed) or aortic regurgitation (the valve does not close properly).
For the Ross procedure, the patient will be given anesthesia, and the surgeon will open the chest to access the heart. The patient will be connected to a cardiopulmonary bypass machine, which takes over the work of the heart and lungs during the procedure.
Then the complex procedure to replace the valves begins. The surgeon will:
- Remove the pulmonary valve and a segment of the main pulmonary artery.
- Remove the diseased aortic valve and aorta.
- Detach the coronary arteries from the aorta.
- Wrap the pulmonary valve and pulmonary artery (the autograft) with a Dacron graft, a synthetic tubelike material that reinforces the natural valve tissue against systemic pressure, stretching, and dilation to prevent leaking or aneurysm.
- Suture the autograft in place of the aortic valve.
- Reattach the coronary arteries.
- Transplant a pulmonary valve and pulmonary segment from a deceased donor in place of the one that has been moved. A human tissue valve is preferred over mechanical options due to a lower risk of blood clots or rejection.
The patient will then be taken off the cardiopulmonary bypass machine so the heart and lungs can resume their jobs. The surgery takes about five hours.
Patients can expect to stay in the hospital usually four to seven days and be on restricted activity for six weeks. They will need to take baby aspirin for a few months after the procedure to reduce the risk of blood clots.
After recovery, most patients go back to living their regular life with minimal restrictions. Talk with a doctor before resuming heavy lifting or vigorous exercise.
Matters of the heart
The Ross procedure is an innovative approach to treating certain types of severe aortic valve disease. Learn more about the procedure from J. Alexander Weston, M.D., and Keri Shafer, M.D., Director of Adult Congenital Heart Disease Program at UT Southwestern.
Why operate on both valves?
You may be wondering why surgery on two valves (the aortic and pulmonary valves) can be better than surgery on just one (the aortic valve). It all goes back to the importance of the aortic valve and the immense amount of pressure it is constantly under from blood being pumped out of the heart and traveling around the body.
A patient’s own tissue often can better adapt to and withstand the high-pressure environment over other valve replacement options. By replacing your aortic valve with your pulmonary valve, we can maximize the long-term function and lower the chance you’ll need a future surgery – as well as eliminate the need for blood thinners.
Meanwhile, the pulmonary valve is under lower pressure, so a donor valve can work just as well there and still last a long time. It’s like promoting a star junior varsity player to varsity – you know they will shine in their new role, and you can substitute a comparable player for their JV spot.
"For people who are good candidates, especially our younger patients, the Ross procedure can provide a more durable replacement valve and allow them to more fully return to their normal active lives."
Options for heart valve replacement
There are several types of heart valve replacement surgery, each with benefits and limitations. Here are three types of procedures that your doctor likely will discuss with you:
- Open heart surgery: The Ross procedure is an example of this type of surgery in which a cardiothoracic surgeon opens the chest to replace the valves while the patient is connected to a cardiopulmonary bypass machine (breathing and heartbeat support).
- Minimally invasive surgery: Rather than vertically splitting the sternum, this approach uses a small horizontal incision in the pectoral area to access the heart. The procedure is also called a mini-thoracotomy.
- Transcatheter aortic valve replacement (TAVR): Approved by the Food and Drug Administration in 2011, this surgery replaces the valve using a catheter inserted in the femoral artery in the groin and guided to the heart.
There are also three types of valves: deceased donor valves, biological (synthetic or animal donor) valves, and mechanical valves. Patients who get deceased donor valves and some biological valves may not need to take lifelong blood thinners. In some cases, the patient “outlives” their biological valve and may need additional surgery.
Mechanical valves can make an audible clicking sound and typically require patients to take blood thinner medication for the rest of their lives. These valves, however, typically last 30 years or longer.
No one type of valve or replacement procedure works for every patient. Each option has criteria to consider, such as which valves are affected, the patient’s overall health, and the risk of needing additional heart surgeries in the future. Talk with a heart surgeon to determine the best option for you.
Who is a good candidate for the Ross procedure?
The Ross procedure can provide lasting, reliable results for aortic valve diseases. Good candidates for the Ross procedure fit one or more of these criteria:
- Are younger than 60 and in otherwise good health
- Have a small aortic valve
- Lead an active lifestyle: Exercising, chasing kids, or working a manual labor job
- Want to become pregnant
- Had a failed mechanical or biological aortic valve from a previous replacement
However, the Ross procedure is not an appropriate choice for patients who have:
- Other major medical problems such as liver, kidney, or lung disease
- Marfan syndrome
- Pulmonary valve disease
- Autoimmune disorders such as lupus or rheumatoid arthritis
- Coronary artery disease in three or more arteries
- Significant mitral valve disease
Because the Ross procedure is complex, patients should seek treatment from a high-volume center like UT Southwestern. For patients with aortic valve disease, getting a valve replacement can provide a new lease on life.
To talk with an expert about treatment options, make an appointment by calling 214-645-7700 or request an appointment online.
