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THE ROSS PROCEDURE

Learn about the Ross procedure for aortic valve replacement.

WHAT IS THE ROSS PROCEDURE?

The Ross procedure is a surgical aortic valve replacement (AVR) technique that uses your own healthy pulmonary valve, called a pulmonary autograft, to replace your damaged aortic valve. A donated, human pulmonary valve, called a pulmonary homograft, is then used to replace your pulmonary valve. 

This procedure was developed by Dr. Donald Ross in 1967 after he realized the human pulmonary valve is a mirror image of the aortic valve.1 It is a living structure that the body immediately accepts, and it can adapt to the higher blood pressure in the aortic position.1-3 It is important to note that the Ross procedure should be performed by a surgeon experienced  with the technique.4

CLICK ON IMAGES TO ENLARGE

BENEFITS OF THE ROSS PROCEDURE

The Ross procedure is the only aortic valve replacement (AVR) operation that restores the life expectancy of patients as if they did not have aortic valve disease.3,5 Other common options for AVR, in which only the aortic valve is replaced, significantly reduce the life expectancy of patients, especially those 60 years of age and younger.5

The reason the Ross procedure does not reduce life expectancy is because the body’s own pulmonary valve is a living structure and provides excellent blood flow across the valve at rest and during exercise. 3,6-7 The pulmonary valve is able to adapt to the higher blood pressure seen on the aortic side of the heart while maintaining its natural biological properties.5

Ross procedure patients experience more “natural” heart function with their own living tissue after AVR, lowering their risk of complications related to valve replacement.2,3 

Main advantages of the Ross procedure include:

  • Normal quality of life with no restrictions to lifestyle5
  • Excellent blood flow across the valve at rest and during exercise6,7
  • No blood thinner medication required1,5
  • Very low risk of blood clot formation5,6
  • Very low risk of valve deterioration or infection5,6

DURABILITY OF THE ROSS PROCEDURE

The Ross procedure has proven, long-term durability as an aortic valve replacement (AVR) option when performed by experienced surgeons in high-volume centers. It is a surgically complex operation, requiring replacement of both the aortic valve and pulmonary valve, thus the success of the procedure largely depends on the surgeon’s expertise.

Recent data proves that the Ross procedure is a very durable AVR option, requiring significantly less reoperation on both the aortic and pulmonary valves when compared to other AVR options.8,9

  • As the figure below illustrates, only 1.5% of patients required reintervention on their aortic valve 10 years after their Ross procedure (Figure A).10
  • In this same study, the total reintervention rate for both the aortic and pulmonary valves combined was only 5% for patients 10 years after their Ross procedure.10

Long-term Reintervention Frequency for the Aortic Valve after a Ross Procedure10

*Adapted from Bouhout et al.10

In addition to surgeon expertise, the durability of the Ross procedure may also depend on the type of replacement pulmonary valve implanted. There are two options when replacing the pulmonary valve with a human donated valve (also called a pulmonary homograft):

  1. “Standard-processed” pulmonary valve; or
  2. “Decellularized” pulmonary valve.

The decellularized pulmonary valve goes through a process called decellularization and has shown to need half the amount of reintervention at 10-years after implantation compared to the standard-processed pulmonary valve.11 In one study following 466 adult Ross procedure patients, all of whom received a decellularized pulmonary valve, only four patients required reintervention on their pulmonary homograft.12

You can learn more about this decellularized pulmonary valve and the decellularization process, called SynerGraft, here.

SynerGraft Pulmonary
Valve (decellularized)
(Processed by Artivion, Inc.)

WHO IS A POTENTIAL CANDIDATE FOR THE ROSS PROCEDURE?

Although the Ross procedure is typically recommended for patients under the age of 50, it is often considered for patients older than 50 who have a projected life expectancy of 15+ years, an active lifestyle, and no other major cardiac disease.5,13 Some additional characteristics of adults who would benefit from the Ross procedure include:

  • Adults who are able to recover from surgical valve replacement
  • Individuals who cannot take a blood thinning medication
  • Women contemplating pregnancy

It is also a preferred aortic valve replacement option for individuals with active lifestyles and no chronic health conditions, such as chronic renal disease or severe coronary artery disease.

Individuals with the following conditions may not be considered a candidate for the Ross procedure: 14

  • Pulmonary valve disease
  • Connective tissue disorders
  • Multi-vessel coronary artery disease

This is not an exhaustive list of potential candidate characteristics and does not apply to all patients. Please consult your physician or healthcare provider for further evaluation and discussion if the Ross procedure is the right AVR option for you.

CONSIDERATIONS FOR THE ROSS PROCEDURE

As with any cardiac surgery, there are considerations for the Ross procedure that should be discussed with your physician or healthcare provider when reviewing your aortic valve replacement (AVR) options.

The success and long-term durability of the Ross procedure is largely dependent on the surgeon’s expertise. This is a surgically complex procedure, and it is important to seek high-volume centers of excellence with aortic surgery, and specifically with the Ross procedure.

Learn about the importance of surgeon expertise with the Ross procedure from Dr. Ismail El-Hamamsy.

Watch Now

A common misconception about the Ross procedure is that it takes a one-valve disease and turns it into a two-valve disease since the procedure requires replacement of two valves (both the aortic and pulmonary valve) instead of just the aortic valve. In reality, there is long-term data out to 15 years after surgery proving that 9 out of 10 Ross procedure patients continue to live without needing a reoperation for either valve.1,2,15-20 Again, note it is important to seek a high-volume center and surgeon of excellence for the Ross procedure.

Watch Dr. Ismail El-Hamamsy debunk this misconception about the Ross procedure.

Watch Now

As with any cardiac surgery, there are risks associated with the Ross procedure, such as reoperation or infection. Please consult your physician or healthcare provider for further information about the risks associated with this type of procedure.

CryoValve® SG Pulmonary Human Heart Valve has not been approved for use as a medical device by Health Canada, and nothing on this website is intended to promote its use in Canada.

  1. Mazine A, et al. (2016). Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study. Circulation, 134, 576-85. https://doi.org/10.1161/CIRCULATIONAHA.116.022800. 
  2. El-Hamamsy I, et al. (2010). Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet, 376(9740), 524-31. https://doi: 10.1016/S0140-6736(10)60828-8. 
  3. El-Hamamsy I, et al. (2013). What Is the Role of the Ross Procedure in Today’s Armamentarium? Canadian Journal of Cardiology, 29, 1569-76. http://dx.doi.org/10.1016/j.cjca.2013.08.009.  
  4. Ouzounian M, et al. (2017). The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults. The Journal of Thoracic and Cardiovascular Surgery, 154(3), 778-82. http://dx.doi.org/10.1016/j.jtcvs.2017.03.156. 
  5. Mazine A, et al. (2018). Ross Procedure in Adults for Cardiologists and Cardiac Surgeons: JACC State-of-the-Art Review. Journal of the American College of Cardiology, 72(22), 2761-77. https://doi.org/10.1016/j.jacc.2018.08.2200. 
  6. Takkenberg J JM, et al. (2009). The Ross Procedure: A Systematic Review and Meta-Analysis.Circulation, 119(2), 222-8. https://doi.org/10.1161/CIRCULATIONAHA.107.726349. 
  7. Laforest I, et al. (2002). Hemodynamic Performance at Rest and During Exercise After Aortic Valve Replacement: Comparison of Pulmonary Autografts Versus Aortic Homografts.Circulation, 106, I-57-62. https://doi.org/10.1161/01.cir.0000032912.33237.bc. 
  8. El-Hamamsy I, et al. (2022). Propensity-Matched Comparison of the Ross Procedure and Prosthetic Aortic Valve Replacement in Adults. Journal of the American College of Cardiology, 79(8), 805–15. https://doi.org/10.1016/j.jacc.2021.11.057. 
  9. Mazine A, et al. (2022). Improved Outcomes Following the Ross Procedure Compared With Bioprosthetic Aortic Valve Replacement. Journal of the American College of Cardiology, 79, 993–1005. https://doi.org/10.1016/j.jacc.2021.12.026. 
  10. Bouhout I, et al. (2024). Long-Term Contemporary Outcomes of the Ross Procedure. Circulation, 150(1). https://doi.org/10.1161/circ.150.suppl_1.4141165.
  11. Bibevski S, et al. (2017). Performance of SynerGraft Decellularized Pulmonary Allografts Compared With Standard Cryopreserved Allografts: Results From Multiinstitutional Data. The Annals of Thoracic Surgery, 103(3), 869–74. https://doi.org/10.1016/j.athoracsur.2016.07.068. 
  12. Chauvette V, et al. (2022). Pulmonary homograft dysfunction after the Ross procedure using decellularized homografts—a multicenter study. The Journal of Thoracic and Cardiovascular Surgery, 163, 1296-305. https://doi.org/10.1016/j.jtcvs.2020.06.139. 
  13. Otto CM, et al. (2021). 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 143(5). https://doi.org/10.1161/CIR.0000000000000923. 
  14. Cook S, et al. (2003). Indications for the Ross operation in children and adults. Progress in Pediatric Cardiology, 16, 133-140. https://doi.org/10.1016/S1058-9813(03)00004-3. 
  15. David T, et al. (2014). The Ross procedure: Outcomes at 20 years. The Journal of Thoracic and Cardiovascular Surgery, 147(1), 85-94. http://dx.doi.org/10.1016/j.jtcvs.2013.08.007. 
  16. Kalfa D, et al. (2015). Long-term outcomes of the Ross procedure in adults with severe aortic stenosis: single-centre experience with 20 years of follow-up. European Journal of Cardio-Thoracic Surgery, 47, 159–67. https://doi.org/10.1093/ejcts/ezu038. 
  17. Sievers HH, et al. (2016). A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry. European Journal of Cardio-Thoracic Surgery,49, 212-18. https://doi.org/10.1093/ejcts/ezv001. 
  18. Skillington P, et al. (2013). Twenty-Year Analysis of Autologous Support of the Pulmonary Autograft in the Ross Procedure. The Annals of Thoracic Surgery, 96, 823–9. http://dx.doi.org/10.1016/j.athoracsur.2013.04.019. 
  19. Andreas M, et al. (2014). A Single-Center Experience With the Ross Procedure Over 20 Years. The Annals of Thoracic Surgery, 97, 182–8. http://dx.doi.org/10.1016/j.athoracsur.2013.08.020. 
  20. Martin E, et al. (2017). Clinical Outcomes Following the Ross Procedure in Adults: A 25-Year Longitudinal Study. Journal of the American College of Cardiology, 70(15), 1890-99. https://doi.org/10.1016/j.jacc.2017.08.030. 

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