Ross procedure
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The Ross procedure, also known as pulmonary autograft, is a heart valve replacement operation to treat severe aortic valve disease, such as in children and young adults with a
bicuspid aortic valve Bicuspid aortic valve (aka BAV) is a form of heart disease in which two of the leaflets of the aortic valve fuse during development in the womb resulting in a two-leaflet (bicuspid) valve instead of the normal three-leaflet (tricuspid) valve. BA ...
. It involves removing the diseased
aortic valve The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. The ...
, situated at the exit of the left side of the heart (where the
aorta The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
begins), and replacing it with the person's own healthy
pulmonary valve The pulmonary valve (sometimes referred to as the pulmonic valve) is a valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. It is one of the four valves of the heart and one of the two semilunar va ...
(autograft), removed from the exit of the heart's right side (where the
pulmonary artery A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and t ...
begins). To reconstruct the right sided exit, a pulmonary valve from a cadaver (homograft), or a stentless
xenograft Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenograft ...
, is used to replace the removed pulmonary valve. Compared to a mechanical valve replacement, it avoids the requirement for thinning the blood, has favourable blood flow dynamics, allows growth of the valve with growth of the child and has less risk of
endocarditis Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the ...
. It is not performed in
Marfan syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with long arms, legs, fingers, and toes. They also typically have exceptionally flexible joints a ...
, if pulmonary valve disease, or if immune problems like
lupus Lupus, technically known as systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Comm ...
. Other contraindications include severe
coronary artery disease Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), myocardial ischemia, or simply heart disease, involves the reduction of blood flow to the heart muscle due to build-up of atherosclerotic pla ...
and severe mitral valve disease. Due to a higher chance of dysfunction of the autograft, it may not always be safe to perform in rheumatic valve disease, or if a dysplastic dilated aortic root. Complications include
endocarditis Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the ...
, degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. It risks having a disease of two valves instead of one. The procedure requires technical expertise. It can be performed using the traditional subcoronary method or more commonly the root replacement technique, which requires re-implanting the coronary arteries. After the operation, good blood pressure control prevents early dilatation of the new aortic root and allows the pulmonary autograft, now in the aortic position, to settle in its new environment. It may need reoperating on at a later date. Complications occur in 3 to 5% of cases, with early death rate almost negligible in very experienced centres. 80% to 90% of cases survive 10 years. As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America. The procedure was first performed using the subcoronary method in 1967 by Donald Ross, for who the procedure is named for. The root replacement method was introduced in the early 1970s. It was continued and modified by others such as
Magdi Yacoub Sir Magdi Habib Yacoub ( ar, د/مجدى حبيب يعقوب ; born 16 November 1935), is an Egyptian retired professor of cardiothoracic surgery at Imperial College London, best known for his early work in repairing heart valves with surgeon ...
, who used fresh valves from the explanted hearts of transplant recipients.


Uses

Several adaptations of the Ross procedure have evolved, but the principle is essentially the same; to replace a diseased
aortic valve The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. The ...
with the person's own
pulmonary valve The pulmonary valve (sometimes referred to as the pulmonic valve) is a valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. It is one of the four valves of the heart and one of the two semilunar va ...
(autograft), and replace the person's own pulmonary valve with a pulmonary valve from a cadaver (homograft) or a stentless
xenograft Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenograft ...
. It is an alternative to a mechanical valve replacement, particularly in children and young adults. It avoids the need for thinning the blood, has favourable blood flow dynamics and the valve grows as the person grows. The most common reason for performing the Ross procedure in children and young adults is for bicuspid aortic valve.


Contra-indications

It is not performed in
Marfan syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with long arms, legs, fingers, and toes. They also typically have exceptionally flexible joints a ...
, if pulmonary valve disease, or if immune problems like
lupus Lupus, technically known as systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Comm ...
. Other contraindications include severe
coronary artery disease Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), myocardial ischemia, or simply heart disease, involves the reduction of blood flow to the heart muscle due to build-up of atherosclerotic pla ...
and severe mitral valve disease. Due to a higher chance of dysfunction of the autograft, it may not always be safe to perform in rheumatic valve disease, or if a dysplastic dilated aortic root.


Risks/complications

The procedure requires technical expertise, and risks converting a single-valve disease into double-valve disease. It may need re-operating on at a later date. Complications include
endocarditis Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the ...
, degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others.


Technique

Before the operation, preparations include
transthoracic echocardiography An echocardiography, echocardiogram, cardiac echo or simply an echo, is an ultrasound of the heart. It is a type of medical imaging of the heart, using standard ultrasound or Doppler ultrasound. Echocardiography has become routinely used in t ...
and measurements of the
ascending aorta The ascending aorta (AAo) is a portion of the aorta commencing at the upper part of the base of the left ventricle, on a level with the lower border of the third costal cartilage behind the left half of the sternum. Structure It passes obliqu ...
and the pulmonary valve. Under
general anaesthesia General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...
, the chest is cut open in the midline. The heart and aorta are exposed before the heart is temporarily stopped and its function taken over
cardiopulmonary bypass Cardiopulmonary bypass (CPB) is a technique in which a machine temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and oxygen to the body. The CPB pump itself is often referred to as a he ...
. Subsequent steps include removing the diseased aortic valve and mobilizing the
coronary arteries The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ of ...
, followed by harvesting and preparing the person's own healthy pulmonary valve, before implanting it within the
left ventricular outflow tract A ventricular outflow tract is a portion of either the left ventricle or right ventricle of the heart through which blood passes in order to enter the great arteries. The right ventricular outflow tract (RVOT) is an infundibular extension of the ...
, the exit of the left side of the heart (where the
aorta The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
begins). Then the coronary artery is reimplanted, before the pulmonary homograft is implanted in the
right ventricular outflow tract A ventricular outflow tract is a portion of either the left ventricle or right ventricle of the heart through which blood passes in order to enter the great arteries. The right ventricular outflow tract (RVOT) is an infundibular extension of the ...
, the exit of the heart's right side (where the
pulmonary artery A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and t ...
begins). The pulmonary autograft is joined to the ascending aorta.


Pulmonary valve replacement

Cryopreserved Cryo-preservation or cryo-conservation is a process where organisms, organelles, cells, tissues, extracellular matrix, organs, or any other biological constructs susceptible to damage caused by unregulated chemical kinetics are preserved by co ...
pulmonary homografts were most often used for a long time until the introduction of decellularized homografts.


Variations

If the left sided outflow root needs to be enlarged to fit the pulmonary autograft, the procedure is called Ross-Konno. An alternative to a pulmonary homograft is the stentless
xenograft Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenograft ...
roots such as the Freestyle Porcine Aortic Root by
Medtronic Medtronic plc is an American medical device company. The company's operational and executive headquarters are in Minneapolis, Minnesota, and its legal headquarters are in Ireland due to its acquisition of Irish-based Covidien in 2015. While it ...
. An external Dacron graft can be used to reinforce the pulmonary autograft.


Recovery

After the operation, good blood pressure control prevents early dilatation of the new aortic root and allows the pulmonary autograft, now in the aortic position, to settle in its new environment. Aftercare includes regular echocardiography and lifelong endocarditis prophylaxis.


Epidemiology

Complications occur in 3% to 5% of cases with one to 3% chance of early death. The death rate is almost negligible in very experienced centres. 80% to 90% of cases survive 10 years, and 70% to 80% may live up to 20 years. As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America.


History

Replacing a diseased aortic valve with an aortic valve from a cadaver was first performed by Donald Ross in England in June 1962, and shortly after in July 1962 by
Brian Barratt-Boyes Sir Brian Gerald Barratt-Boyes (born Brian Gerald Boyes, 13 January 1924 – 8 March 2006) was a pioneering New Zealand cardiothoracic surgeon. He was known for early development of cardiopulmonary bypass surgery, early implantation of a cardi ...
in Auckland, New Zealand. In 1967 Ross took the normal pulmonary valve of a person with severe aortic valve disease, and placed it in the aortic position where the diseased aortic valve was removed. To reconstruct the missing pulmonary outflow tract, a homograft stored and sterilised from a cadaver was used to replace the removed pulmonary valve. In 1972, Ross introduced the technique using the root replacement method. For 30 years he was almost the only surgeon performing the procedure, until it gained popularity.
Marian Ionescu Marian Ion Ionescu (born 21 August 1929 in Târgoviște) is a Romanian-born British cardiac surgeon. His interest in heart surgery covered several aspects of this specialty. He was an inventor of surgical devices, mostly artificial heart valve ...
in Leeds, in an attempt to seek other materials, unsuccessfully tried
fascia lata The fascia lata is the deep fascia of the thigh. It encloses the thigh muscles and forms the outer limit of the fascial compartments of thigh, which are internally separated by the medial intermuscular septum and the lateral intermuscular septu ...
from the person's own thigh to create a living valve. He then tried successfully with cattle pericardium fixed with
glutaraldehyde Glutaraldehyde is an organic compound with the formula . The molecule consists of a five carbon chain doubly terminated with formyl (CHO) groups. It is usually used as a solution in water, and such solutions exists as a collection of hydrates, c ...
, and the procedure became widespread before then falling out of favour as they failed. Then came pig valves (xenograft) before the 1980s trend for mechanical valves. The Ross procedure was continued and modified by
Magdi Yacoub Sir Magdi Habib Yacoub ( ar, د/مجدى حبيب يعقوب ; born 16 November 1935), is an Egyptian retired professor of cardiothoracic surgery at Imperial College London, best known for his early work in repairing heart valves with surgeon ...
, who used fresh valves from the explanted hearts of transplant recipients.


Etymology

It has also been called the double-switch Ross procedure.


Society

In 1997, to replace a
bicuspid aortic valve Bicuspid aortic valve (aka BAV) is a form of heart disease in which two of the leaflets of the aortic valve fuse during development in the womb resulting in a two-leaflet (bicuspid) valve instead of the normal three-leaflet (tricuspid) valve. BA ...
, the Ross procedure was performed on
Arnold Schwarzenegger Arnold Alois Schwarzenegger (born July 30, 1947) is an Austrian and American actor, film producer, businessman, retired professional bodybuilder and politician who served as the 38th governor of California between 2003 and 2011. ''Time'' ...
. The procedure was more popular in the 1990s and then declined in use over the subsequent 20 years. Data relating to the procedure is held in the Ross registry.


Other animals

The procedure has been carried out in pigs and sheep for the purpose of research.


Footnotes


References


Further reading

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External links

{{cardiac surgery Cardiac surgery Valvular heart disease