Ross procedure

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Ross procedure
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Ross Procedure
Other namesPulmonary autograft, switch procedure, double-switch Ross procedure
Specialty Cardiac surgery
UsesAortic valve disease [1]
Approach Median sternotomy [1]
TypesSubcoronary method, root replacement technique [2]
OutcomesGood if performed in specialist centre, [1] 80% to 90% 10 year survival. [3]

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. [1] It involves removing the diseased aortic valve, situated at the exit of the left side of the heart (where the aorta begins), and replacing it with the person's own healthy pulmonary valve (autograft), removed from the exit of the heart's right side (where the pulmonary artery begins). [4] To reconstruct the right sided exit, a pulmonary valve from a cadaver (homograft), or a stentless xenograft, is used to replace the removed pulmonary valve. [1] [lower-alpha 1] 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. [1]

Contents

It is not performed in Marfan syndrome, if pulmonary valve disease, or if immune problems like lupus. [3] Other contraindications include severe coronary artery disease and severe mitral valve disease. [3] 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. [6] Complications include endocarditis, degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. [1] [2] It risks having a disease of two valves instead of one. [7]

The procedure requires technical expertise. [4] It can be performed using the traditional subcoronary method or more commonly the root replacement technique, which requires re-implanting the coronary arteries. [8] [9]

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. [10] It may need reoperating on at a later date. [7] Complications occur in 3 to 5% of cases, with early death rate almost negligible in very experienced centres. [3] 80% to 90% of cases survive 10 years. [3] As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America. [1]

The procedure was first performed using the subcoronary method in 1967 by Donald Ross, for who the procedure is named for. [8] [11] The root replacement method was introduced in the early 1970s. [8] It was continued and modified by others such as Magdi Yacoub, who used fresh valves from the explanted hearts of transplant recipients. [11]

Uses

Diagram of the human heart Diagram of the human heart (cropped).svg
Diagram of the human heart

Several adaptations of the Ross procedure have evolved, but the principle is essentially the same; to replace a diseased aortic valve with the person's own pulmonary valve (autograft), and replace the person's own pulmonary valve with a pulmonary valve from a cadaver (homograft) or a stentless xenograft. [1] [4] It is an alternative to a mechanical valve replacement, particularly in children and young adults. [7] It avoids the need for thinning the blood, has favourable blood flow dynamics and the valve grows as the person grows. [7]

The most common reason for performing the Ross procedure in children and young adults is for bicuspid aortic valve. [1]

Contra-indications

It is not performed in Marfan syndrome, if pulmonary valve disease, or if immune problems like lupus. [3] Other contraindications include severe coronary artery disease and severe mitral valve disease. [3] 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. [6]

Risks/complications

The procedure requires technical expertise, and risks converting a single-valve disease into double-valve disease. [4] It may need re-operating on at a later date. [7] Complications include endocarditis, degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. [1] [2]

Technique

Before the operation, preparations include transthoracic echocardiography and measurements of the ascending aorta and the pulmonary valve. [10] Under general anaesthesia, the chest is cut open in the midline. [3] The heart and aorta are exposed before the heart is temporarily stopped and its function taken over cardiopulmonary bypass. [3] Subsequent steps include removing the diseased aortic valve and mobilizing the coronary arteries, followed by harvesting and preparing the person's own healthy pulmonary valve, before implanting it within the left ventricular outflow tract, the exit of the left side of the heart (where the aorta begins). [1] [10] Then the coronary arteries are reimplanted, before the pulmonary homograft is implanted in the right ventricular outflow tract, the exit of the heart's right side (where the pulmonary artery begins). [1] [10] The pulmonary autograft is joined to the ascending aorta. [1] [10]

Pulmonary valve replacement

Cryopreserved pulmonary homografts were most often used for a long time until the introduction of decellularized homografts. [2]

Variations

If the left sided outflow root needs to be enlarged to fit the pulmonary autograft, the procedure is called Ross-Konno. [3] An alternative to a pulmonary homograft is the stentless xenograft roots such as the Freestyle Porcine Aortic Root by Medtronic. [2] [12] An external Dacron graft can be used to reinforce the pulmonary autograft. [2]

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. [10] Aftercare includes regular echocardiography and lifelong endocarditis prophylaxis. [1]

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. [3] As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America. [1]

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 in Auckland, New Zealand. [11] [13] 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. [11] To reconstruct the missing pulmonary outflow tract, a homograft stored and sterilised from a cadaver was used to replace the removed pulmonary valve. [11] In 1972, Ross introduced the technique using the root replacement method. [13] For 30 years he was almost the only surgeon performing the procedure, until it gained popularity. [11] Marian Ionescu in Leeds, in an attempt to seek other materials, unsuccessfully tried fascia lata from the person's own thigh to create a living valve. [11] He then tried successfully with cattle pericardium fixed with glutaraldehyde, and the procedure became widespread before then falling out of favour as they failed. [11] Then came pig valves (xenograft) before the 1980s trend for mechanical valves. [11] The Ross procedure was continued and modified by Magdi Yacoub, who used fresh valves from the explanted hearts of transplant recipients. [11]

Etymology

It has also been called the double-switch Ross procedure. [14]

Society

In 1997, to replace a bicuspid aortic valve, the Ross procedure was performed on Arnold Schwarzenegger. [15]

The procedure was more popular in the 1990s and then declined in use over the subsequent 20 years. [16] Data relating to the procedure is held in the Ross registry. [17]

Other animals

The procedure has been carried out in pigs and sheep for the purpose of research. [18]

Footnotes

  1. ↑ With reference to valves, homograft refers to a valve from another human, xenograft usually from pig, and autograft as moving one valve from one place to another in the same person. [5]

Related Research Articles

<span class="mw-page-title-main">Aorta</span> Largest artery in the human body

The aorta is the main and largest artery in the human body, originating from the left ventricle of the heart, branching upwards immediately after, and extending down to the abdomen, where it splits at the aortic bifurcation into two smaller arteries. The aorta distributes oxygenated blood to all parts of the body through the systemic circulation.

<span class="mw-page-title-main">Aortic stenosis</span> Narrowing of the exit of the hearts left ventricle

Aortic stenosis is the narrowing of the exit of the left ventricle of the heart, such that problems result. It may occur at the aortic valve as well as above and below this level. It typically gets worse over time. Symptoms often come on gradually with a decreased ability to exercise often occurring first. If heart failure, loss of consciousness, or heart related chest pain occur due to AS the outcomes are worse. Loss of consciousness typically occurs with standing or exercising. Signs of heart failure include shortness of breath especially when lying down, at night, or with exercise, and swelling of the legs. Thickening of the valve without narrowing is known as aortic sclerosis.

<span class="mw-page-title-main">Aortic valve</span> Valve in the human heart between the left ventricle and the aorta

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 aortic valve normally has three cusps or leaflets, although in 1–2% of the population it is found to congenitally have two leaflets. The aortic valve is the last structure in the heart the blood travels through before stopping the flow through the systemic circulation.

<span class="mw-page-title-main">Aortic regurgitation</span> Medical condition

Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a consequence, the cardiac muscle is forced to work harder than normal.

<span class="mw-page-title-main">Aneurysm of sinus of Valsalva</span> Medical condition

Aneurysm of the aortic sinus, also known as the sinus of Valsalva, is a rare abnormality of the aorta, the largest artery in the body. The aorta normally has three small pouches that sit directly above the aortic valve, and an aneurysm of one of these sinuses is a thin-walled swelling. Aneurysms may affect the right (65–85%), non-coronary (10–30%), or rarely the left coronary sinus. These aneurysms may not cause any symptoms but if large can cause shortness of breath, palpitations or blackouts. Aortic sinus aneurysms can burst or rupture into adjacent cardiac chambers, which can lead to heart failure if untreated.

Aortic valve replacement is a procedure whereby the failing aortic valve of a patient's heart is replaced with an artificial heart valve. The aortic valve may need to be replaced because:

<span class="mw-page-title-main">Magdi Yacoub</span> Egyptian retired professor and surgeon (born 1935)

Sir Magdi Habib Yacoub, is an Egyptian retired professor of cardiothoracic surgery at Imperial College London, best known for his early work in repairing heart valves with surgeon Donald Ross, adapting the Ross procedure, where the diseased aortic valve is replaced with the person's own pulmonary valve, devising the arterial switch operation (ASO) in transposition of the great arteries, and establishing the heart transplantation centre at Harefield Hospital in 1980 with a heart transplant for Derrick Morris, who at the time of his death was Europe's longest-surviving heart transplant recipient. Yacoub subsequently performed the UK's first combined heart and lung transplant in 1983.

The Rastelli procedure is an open heart surgical procedure developed by Italian physician and cardiac surgery researcher, Giancarlo Rastelli, in 1967 at the Mayo Clinic, and involves using a pulmonary or aortic homograft conduit to relieve pulmonary obstruction in double outlet right ventricle with pulmonary stenosis.

<span class="mw-page-title-main">Artificial heart valve</span> Replacement of a valve in the human heart

An artificial heart valve is a one-way valve implanted into a person's heart to replace a heart valve that is not functioning properly. Artificial heart valves can be separated into three broad classes: mechanical heart valves, bioprosthetic tissue valves and engineered tissue valves.

<span class="mw-page-title-main">Arterial switch operation</span> Open heart surgical procedure

Arterial switch operation (ASO) or arterial switch, is an open heart surgical procedure used to correct dextro-transposition of the great arteries (d-TGA).

<span class="mw-page-title-main">Ascending aorta</span> Part of the heart

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.

The Bentall procedure is a type of cardiac surgery involving composite graft replacement of the aortic valve, aortic root, and ascending aorta, with re-implantation of the coronary arteries into the graft. This operation is used to treat combined disease of the aortic valve and ascending aorta, including lesions associated with Marfan syndrome. The Bentall procedure was first described in 1968 by Hugh Bentall and Antony De Bono. It is considered a standard for individuals who require aortic root replacement, and the vast majority of individuals who undergo the surgery receive mechanical valves.

<span class="mw-page-title-main">Anomalous left coronary artery from the pulmonary artery</span> Medical condition

Anomalous left coronary artery from the pulmonary artery is a rare congenital anomaly occurring in approximately 1 in 300,000 liveborn children. The diagnosis comprises between 0.24 and 0.46% of all cases of congenital heart disease. The anomalous left coronary artery (LCA) usually arises from the pulmonary artery instead of the aortic sinus. In fetal life, the high pressure in the pulmonic artery and the fetal shunts enable oxygen-rich blood to flow in the LCA. By the time of birth, the pressure will decrease in the pulmonic artery and the child will have a postnatal circulation. The myocardium which is supplied by the LCA, will therefore be dependent on collateral blood flow from the other coronary arteries, mainly the RCA. Because the pressure in RCA exceeds the pressure in LCA a collateral circulation will increase. This situation ultimately can lead to blood flowing from the RCA into the LCA retrograde and into the pulmonary artery, thus forming a left-to-right shunt.

Minimally invasive cardiac surgery, also known as MICS CABG or the McGinn technique is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach. MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

Donald Nixon Ross, FRCS was a South African-born British thoracic surgeon who was a pioneer of cardiac surgery and led the team that carried out the first heart transplantation in the United Kingdom in 1968. He developed the pulmonary autograft, known as the Ross procedure, for treatment of aortic valve disease.

<span class="mw-page-title-main">Open aortic surgery</span> Surgical technique

Open aortic surgery (OAS), also known as open aortic repair (OAR), describes a technique whereby an abdominal, thoracic or retroperitoneal surgical incision is used to visualize and control the aorta for purposes of treatment, usually by the replacement of the affected segment with a prosthetic graft. OAS is used to treat aneurysms of the abdominal and thoracic aorta, aortic dissection, acute aortic syndrome, and aortic ruptures. Aortobifemoral bypass is also used to treat atherosclerotic disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by endovascular aneurysm repair (EVAR) as the most common technique for repairing abdominal aortic aneurysms in the United States.

<span class="mw-page-title-main">Decellularized homografts</span>

Decellularized homografts are donated human heart valves which have been modified via tissue engineering. Several techniques exist for decellularization with the majority based on detergent or enzymatic protocols which aim to eliminate all donor cells while preserving the mechanical properties of the remaining matrix.

The LeCompte maneuver is a technique used in open heart surgery, primarily on infants and children. The maneuver entails cutting the main pulmonary artery and moving it anterior to the aorta before reattaching the pulmonary artery during the following reconstruction of the great vessels. It allows the surgeon to reconstruct the right ventricular outflow tract without needing to connect the proximal and distal sections with a graft. It also enables the surgeon to avoid compressing the coronary arteries and relieves compression of the bronchi in cases where the pulmonary artery is severely dilated or aneurysmal. If both pulmonary arteries are not mobilized adequately, they can become stretched, leading to pulmonic stenosis.

The Yasui procedure is a pediatric heart operation used to bypass the left ventricular outflow tract (LVOT) that combines the aortic repair of the Norwood procedure and a shunt similar to that used in the Rastelli procedure in a single operation. It is used to repair defects that result in the physiology of hypoplastic left heart syndrome even though both ventricles are functioning normally. These defects are common in DiGeorge syndrome and include interrupted aortic arch and LVOT obstruction (IAA/LVOTO); aortic atresia-severe stenosis with ventricular septal defect (AA/VSD); and aortic atresia with interrupted aortic arch and aortopulmonary window. This procedure allows the surgeon to keep the left ventricle connected to the systemic circulation while using the pulmonary valve as its outflow valve, by connecting them through the ventricular septal defect. The Yasui procedure includes a modified Damus–Kaye–Stansel procedure to connect the aortic and pulmonary roots, allowing the coronary arteries to remain perfused. It was first described in 1987.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Bouhout, Ismail; Hammamsy, Ismail (2020). "38. The Ross procedure". In Raja, Shahzad G. (ed.). Cardiac Surgery: A Complete Guide. Switzerland: Springer. pp. 351–358. ISBN   978-3-030-24176-6.
  2. 1 2 3 4 5 6 Nappi, Francesco; Singh, Sanjeet Singh Avtaar; Bellomo, Francesca; Nappi, Pierluigi; Iervolino, Adelaide; Acar, Christophe (2021). "The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer". BioMed Research International. 2021: 5547342. doi: 10.1155/2021/5547342 . ISSN   2314-6141. PMC   8060091 . PMID   33937396.
  3. 1 2 3 4 5 6 7 8 9 10 11 Brown, Kristen N.; Kanmanthareddy, Arun (2022). "Ross Procedure for Aortic Valve Replacement". Aortic Valve Ross Operation. PMID   30725934.{{cite book}}: |journal= ignored (help)
  4. 1 2 3 4 Moroi, Morgan K.; Bacha, Emile A.; Kalfa, David M. (2021). "The Ross procedure in children: a systematic review". Annals of Cardiothoracic Surgery. 10 (4): 420–432. doi: 10.21037/acs-2020-rp-23 . ISSN   2225-319X. PMC   8339620 . PMID   34422554.
  5. ↑ Bunce, Nicholas H.; Ray, Robin; Patel, Hitesh (2020). "30. Cardiology". In Feather, Adam; Randall, David; Waterhouse, Mona (eds.). Kumar and Clark's Clinical Medicine (10th ed.). Elsevier. p. 1102. ISBN   978-0-7020-7870-5.
  6. 1 2 Morita, K.; Kurosawa, H. (April 2001). "[Indications for and clinical outcome of the Ross procedure: a review]". Nihon Geka Gakkai Zasshi. 102 (4): 330–336. ISSN   0301-4894. PMID   11344686.
  7. 1 2 3 4 5 Etnel, Jonathan R.G.; Grashuis, Pepijn; Huygens, Simone A.; Pekbay, Begüm; Papageorgiou, Grigorios; Helbing, Willem A.; Roos-Hesselink, Jolien W.; Bogers, Ad J.J.C.; Mokhles, M. Mostafa; Takkenberg, Johanna J.M. (1 December 2018). "The Ross Procedure: A Systematic Review, Meta-Analysis, and Microsimulation". Circulation: Cardiovascular Quality and Outcomes. 11 (12): e004748. doi: 10.1161/CIRCOUTCOMES.118.004748 . PMID   30562065. S2CID   56477833.
  8. 1 2 3 Van Hoof, Lucas; Verbrugghe, Peter; Jones, Elizabeth A. V.; Humphrey, Jay D.; Janssens, Stefan; Famaey, Nele; Rega, Filip (9 February 2022). "Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts". Frontiers in Cardiovascular Medicine. 9: 829120. doi: 10.3389/fcvm.2022.829120 . ISSN   2297-055X. PMC   8865563 . PMID   35224059.
  9. ↑ Tweddell, James S. (4 January 2021). "The root replacement remains the gold standard for the Ross procedure". European Journal of Cardio-Thoracic Surgery. 59 (1): 234–235. doi: 10.1093/ejcts/ezaa366 . ISSN   1873-734X. PMID   33188684.
  10. 1 2 3 4 5 6 Mazine, Amine; Ghoneim, Aly; El-Hamamsy, Ismail (1 May 2018). "The Ross Procedure: How I Teach It". The Annals of Thoracic Surgery. 105 (5): 1294–1298. doi: 10.1016/j.athoracsur.2018.01.048 . ISSN   0003-4975. PMID   29481789.
  11. 1 2 3 4 5 6 7 8 9 10 Treasure, Tom (2000). "16. Cardiac surgery". In Silverman, Mark E.; Fleming, Peter R.; Hollman, Arthur; Julian, Desmond G.; Krikler, Dennis M. (eds.). British Cardiology in the 20th Century. Springer. p. 206. ISBN   978-1-4471-1199-3.
  12. ↑ Kırali, Kaan; Gunay, Deniz (2017). "2. Isolated aortic root aneurysms". In Kırali, Kaan (ed.). Aortic Aneurysm. BoD – Books on Demand. p. 29. ISBN   978-953-51-2933-2.
  13. 1 2 Yankah, A Charles (June 2002). "Forty Years of Homograft Surgery". Asian Cardiovascular and Thoracic Annals. 10 (2): 97–100. doi: 10.1177/021849230201000201 . ISSN   0218-4923. PMID   12079928. S2CID   33689209.
  14. ↑ Chang, Jen-Ping; Kao, Chiung-Lun; Hsieh, Ming-Jang (1 June 2002). "Double-switch Ross procedure". The Annals of Thoracic Surgery. 73 (6): 1988–1989. doi:10.1016/S0003-4975(02)03460-4. ISSN   0003-4975. PMID   12078818.
  15. ↑ "Arnold Schwarzenegger's Heart Valve Surgeries (2020 Update)". www.heart-valve-surgery.com. Retrieved 8 February 2022.
  16. ↑ Mazine, Amine; Rocha, Rodolfo V.; El-Hamamsy, Ismail; Ouzounian, Maral; Yanagawa, Bobby; Bhatt, Deepak L.; Verma, Subodh; Friedrich, Jan O. (October 2018). "Ross Procedure vs Mechanical Aortic Valve Replacement in Adults". JAMA Cardiology. 3 (10): 978–987. doi:10.1001/jamacardio.2018.2946. ISSN   2380-6583. PMC   6233830 . PMID   30326489.
  17. ↑ Aboud, Anas; Charitos, Efstratios I.; Fujita, Buntaro; Stierle, Ulrich; Reil, Jan-Christian; Voth, Vladimir; Liebrich, Markus; Andreas, Martin; Holubec, Tomas; Bening, Constanze; Albert, Marc; Fila, Petr; Ondrasek, Jiri; Murin, Peter; Lange, Rüdiger; Reichenspurner, Hermann; Franke, Ulrich; Gorski, Armin; Moritz, Anton; Laufer, Günther; Hemmer, Wolfgang; Sievers, Hans-Hinrich; Ensminger, Stephan (23 March 2021). "Long-Term Outcomes of Patients Undergoing the Ross Procedure". Journal of the American College of Cardiology. 77 (11): 1412–1422. doi: 10.1016/j.jacc.2021.01.034 . PMID   33736823. S2CID   232297352.
  18. ↑ Van Hoof, Lucas; Claus, Piet; Jones, Elizabeth A. V.; Meuris, Bart; Famaey, Nele; Verbrugghe, Peter; Rega, Filip (July 2021). "Back to the root: a large animal model of the Ross procedure". Annals of Cardiothoracic Surgery. 10 (4): 444–453. doi: 10.21037/acs-2020-rp-21 . ISSN   2225-319X. PMC   8339627 . PMID   34422556.

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