Ross procedure: the treatment of choice for aortic valve disease?

Abstract

The Ross or pulmonary autograft procedure, demechanical valves. Ten and 20 years after the proscribed and pioneered by Mr. Donald Ross [1] in cedure 85 and 61% of hospital survivors from the 1967, involves replacement of the diseased aortic pioneer series [4] were alive, with 88 and 75% valve with the patient’s own pulmonary valve (autofreedom from autograft replacement and 89 and 80% graft) and implantation of a homograft valve in the freedom from replacement of the pulmonary homopulmonary position. The pulmonary autograft valve graft, respectively. These results compare favourably in the aortic position remains viable, does not calcify, to any other bioprosthetic valve replacement [6,8]. has the potential to grow, does not require anticoaguMore recently, a reduced incidence of neo-aortic lation and is rarely associated with histologic degenevalve regurgitation and reoperation at mid-term folration [2–5]. Despite these obvious advantages, the low-up has been reported [2,3,6] with the implantaRoss procedure was not initially adopted widely tion of the pulmonary valve and the pulmonary artery because the operation is longer and more complex, it as an anatomical unit (root method) compared to the commits the patient and the surgeon to double valve sub-coronary technique, primarily employed by Mr. surgery, and the early morbidity and mortality during Ross [1]. Furthermore, Elkins and colleagues [9] the learning curve were substantial. However, with described the insertion of the pulmonary cylinder improved surgical techniques, better myocardial using the aortic root inclusion technique. Fixation of protection – during cardiopulmonary bypass – and the autograft root to the relatively dense collagen the availability of commercially prepared homografts structure of the aortic ‘‘annulus’’ and its implantation in the 1980s, a late interest and wider experience within the native aorta seems to prevent distortion of [2,3,6,7] with the Ross procedure have been accumuthe commissures and – by providing external support lated in recent years. – minimises dilatation of the pulmonary autograft. Reoperation for neo-aortic valve regurgitation has Subsequently, Pacifico et al. [10] utilised bovine been the major complication following the Ross pericarial circumferential wrap to support the distensprocedure [4]. Failure of the pulmonary autograft has ible root and reduce postoperative bleeding. been attributable to technical errors at the time of In a previous issue of the Journal Santini and operation, progressive aortic regurgitation due to colleagues [11] report their experience with 26 young inadequate coaptation of the leaflets or pulmonary adults who underwent the pulmonary autograft proautograft-to-aortic ‘‘annulus’’ mismatch [7]. Transcedure. There were no early or late deaths. At a mean valvar pressure gradients after the Ross procedure are follow-up of 22.5 months, more than mild aortic negligible and clearly better than for bioprostheses or regurgitation was seen in one (4%) patient. This was the only patient from the series who had a subcoronary and not a root implantation and who required *Tel.: 144-171-351-8602; fax: 144-171-351-8629. E-mail address: m.gatzoulis@rbh.nthames.nhs.uk (M.A. Gatzoulis) reoperation. These results compare favourably with