Ross Procedure - Indications, Contraindications, Procedure, And Complications

Introduction:

The Ross procedure is a significant cardiovascular surgery in which the aortic valve is replaced with the pulmonary valve. This autografted pulmonary valve has the capacity to grow and exerts less pressure on the right-sided pulmonary valve replacement, leading to a higher success rate. This surgery has lower rates of mortality, thromboembolism (obstruction of blood vessels by a blood clot), bleeding, and endocarditis (inflammation of the heart's inner lining).

What Is Ross Procedure?

Ross procedure is also called pulmonary autograft or switch procedure, a cardiac surgery in which the diseased, non-functioning aortic valve is replaced with a pulmonary valve, and the pulmonary valve is replaced with pulmonary allograft.

What Are The Indications Of The Ross Procedure?

The indications of the Ross procedure are:

• Infants or children who have aortic valve disease (heart disease where the valve between the left ventricle and aorta does not function properly) with congenital aortic stenosis (the cusps of the aorta becomes stiff and thick, causing reduced blood flow or blockage of blood flow because of the narrow passages).

• Young females with bicuspid aortic valve (a heart condition where the aortic valve has two cusps instead of three) and small aortic annulus.

• Severe aortic valve disease, which cannot be repaired.

• Adult aortic regurgitation (a heart condition where the aortic valve does not close enough during diastole, which causes reverse blood flow through the aortic valve) with a dilated aorta.

• Native (own) or prosthetic valve endocarditis (infection of heart valves).

• Left ventricular outflow tract obstruction (limited blood flow from the left ventricle).

What Are The Contraindications Of The Ross Procedure?

The contraindications of the Ross procedure are:

• Pulmonary valve disease (a heart condition that affects the valve between the right ventricle and the pulmonary artery that supplies blood to the lungs).

• Marfan syndrome (connective tissue disorder that affects main organs such as the heart, skeleton, eyes, and blood vessels).

• Lupus (an autoimmune disorder where the body’s immune system attacks its organs like the heart, lungs, blood vessels, brain, kidney, joints, and skin).

• Advanced three-vessel coronary artery disease.

• Rheumatic valve disease (condition of the heart where the heart valves are damaged due to rheumatic fever, an inflammatory condition of the heart, joints, or skin which occurs as a complication of strep throat or scarlet fever).

• Dysplastic dilated aortic root.

• Mitral valve disease (a heat disorder affecting the left heart chambers valve).

How Is The Ross Procedure Performed?

Before the procedure, the echocardiogram should assess the aortic valve and pulmonary valve for stenosis or regurgitation, the size of the aortic and pulmonary annulus, and other abnormalities, such as left ventricular outflow tract obstruction. An aortic root enlargement procedure should be done in the case of a small aortic annulus. The steps involved are:

• The preoperative procedure involves shaving the chest, sterilizing it, and placing sterile drapes, and antibiotics are given This procedure is done under general anesthesia.

• The procedure uses median sternotomy, where a vertical incision is made along the sternum (breast bone) to expose the heart and aorta. Cardiopulmonary bypass is used, providing a bloodless field during surgery.

• The aorta is opened about a centimeter above from the origin of the right coronary artery, and the aortic valve is inspected. Then, The damaged aortic valve is excised, and coronary buttons are prepared.

• The pulmonary artery (PA) is incised transversely proximal to the bifurcation, the pulmonary valve is inspected for any abnormality, and the valve is excised; the pulmonary valve is replaced using the full root approach because of its less risk of pulmonary autograft failure.

• The full root approach involves mobilizing the root and elevating it from the surgical plane. The posterior section of the pulmonary artery root is incised, allowing visualization of the right ventricular outflow tract. Subsequently, the pulmonary root is separated from the aorta, and a clamp is used to identify the most proximal region to the pulmonary valve. By dividing the anterior portion and scoring the posterior muscle of the right ventricle, the pulmonary artery root is dissected, and the aortic valve and root are then removed.

• After removing the pulmonary valve, it is prepared for implantation into the aortic root.

• The pulmonic autograft is linked to the left ventricular outflow tract, and the right and left coronary arteries are re-implanted on the autograft.

• A pulmonary homograft is trimmed and implanted into the pulmonary root.

• Weaning from cardiopulmonary bypass is done, which involves a transition from the mechanical respiratory and cardiac support to the patient’s heart and lungs.

• A transesophageal echocardiogram is done to evaluate the function of autograft and homograft. The pulmonary and aortic valve functions are also evaluated.

• The patient is examined every four to six weeks using an echocardiogram.

What Are The Benefits Of The Ross Procedure?

The benefits of the Ross procedure include the following:

• The autografted pulmonary valve has the ability to grow, making it superior to prosthetic valves.

• No anticoagulants are required.

• Minimal restrictions in the lifestyle.

• Excellent hemodynamics (flow of blood).

• Quick recovery.

• No postoperative deterioration of the valve from calcification.

What Are The Complications Of The Ross Procedure?

Complications occur in three to five percent of patients, and 70 to 80 % have long-term survival. The complications include:

• Early autograft failure.

• Pulmonary regurgitation or stenosis because of calcific degeneration.

• Distortion of the valve.

• Aortic regurgitation.

• Aortic insufficiency.

• Right ventricular outflow tract obstruction (obstruction in the right ventricle).

• Aortic autograft dilatation.

• Myocardial infarction (heart attack caused by decreased blood flow to a part of the myocardium, the heart's muscular tissue).

• Pulmonary allograft stenosis (narrowing of the valve).

• Hemorrhage.

• Drug reactions.

• Infection.

• Arrhythmia (irregular heartbeat).

• Respiratory distress.

Conclusion:

The Ross procedure is superior to other prosthetic valves; patients do not require anticoagulants and minimal restrictions in their lifestyle, though; lifelong heart monitoring is required. The success of this operation depends on the surgeon’s experience and collaborative inter-professional team approach, which involves surgeons, cardiac nursing specialists, and trained cardiac pharmacists. But the introduction of transcatheter valve replacements does not require open heart surgery which is in the case of the Ross procedure.