Ross Procedure

[Ben Smith]

Is the "Ross Procedure" a viable option for a 27 year old male with  3+ to 4+ aortic regurgitation and an ascending aortic aneurysm that measures 5.3 to 5.5cm?
Are there any complications with this procedure that I should know prior to adding that to my decision on which valve to take if mine is unrepairable?
Isn't the Pulmonary valve replaced with a cadiver valve in this procedure? Or what are the options for replacing the Pulmonary valve after it is moved to the aortic location?
Thank you.

Ben

[Cleveland Clinic, MD]

Dear Ben,

There are three main options for aortic valve replacement: mechanical replacement, tissue replacement, and the Ross procedure.  Examples of mechanical valves are St.Jude, Star-Edwards and Medtronic-Hall.  The advantage of the mechanical valve is its long life (usually longer than the person receiving it).  The disadvantage is the need for life-long coumadin. There are no long term complications from taking coumadin other than the bleeding risks.

Tissue valves are made from pig or cow hearts and last about 5- 10 years.  The main advantage is not having to take coumadin.  Aortic homografts are tissue valves from cadavers and also do not require anticoagulation and may last longer than other types of tissue valves.  No one really knows how long but it is probably more than 10 - 15 years.  The chief disadvantage of the homograft is availability.  

The Ross procedure transplants the patients own pulmonic valve to the aortic position and places a tissue valve in the pulmonic position.  We have one surgeon who is doing this procedure here - Dr. Petterson and he would be the one to talk to if you are interested in this option.

Ultimately the choice is between you and your doctor.

[Todd W]

I had an asc aorta aneurysm and valve repair (David Procedure) in 1998 at age 33.  I was told that because of my "weak elastic tissue" that a ross may not be a good option - the pulmonary valve root may dialate in the aortic position.  I was able to have my valve spared by Dr. David  himself (Toronto Hospital).  It was worth the trip to Toronto and my HMO did pay for the operation (I live in Michigan).  12 weeks post op I was back playing hockey.  I run 15 mile a week and feel great.  Feel free to e mail me at todd.***@****.  Good luck!

[Gary]

You should be aware of the most critical aspect of heart surgery: The time you are on by-pass and cross-clamp.

Only one surgeon I spoke with emphasized that many surgeons are highly skilled and technically proficient but the time they take to perform a given procedure is all over the map.

The most risky part of open heart surgery is the possibility of on the table and post-op strokes, embolisms, and thrombo events that can render a perfectly done Ross or any other procedure moot.

At age 27 you are a likely candidate for the Ross procedure but the aneurysm may rule it out. If not, weigh the odds very carefully. There's 1% chance of something going wrong on the table with a mechanical implant that has you on by-pass for about 45 minutes. Ditto, a bovine pericardial valve.

But the trade offs of coumadin for life in the first instance and re-op within 5-15 yrs for the Bovine may not be what you want either.

The Ross is a long procedure even in the best hands. For the very young it may be the best option because the pulmonic valve is 'live' and grows with the patient to maturity. In a mature person, other valve options may be much safer.  What scared me off of the Ross were two things: 1) The time of the operation and particularly the time on by-pass and 2)a documented 12-15% Re-op rate on the AV or Pulmonic valve within a few months or years of and a near certainty of re-op on the cadaveric pulmmonic valve within 15-25 yrs. I figured if opening my chest again was a virtual certainty in both the Bovine implant and the Ross, I wanted the surgery and the re-op that had me on by-pass the least amount of time in both instances. Didnt't want my heart stopped for 2-4 hours at one time, but 45 minutes each time instead.

I could go into more but not here as it takes up too much bandwidth. Feel free to email me at <***@****> if you wish to.

[Todd W]

Again, there is another option and that is the valve sparing procedure(David (reimplantation) or Yacoub (remodelling) procedures). Only a few centers do this successfully, but the benefits are quite good.  Durability of the native valve looks very promising (some may last a lifetime), lower instance of infective endocarditis and other complications.  The draw backs are that it is technically demanding, not widely accepted, data only exists for a little over a decade, and there is a chance that your valve cannot be spared (final determination during surgery so you need to have a back-up, ie replacement ready). Some days I felt like throwing darts to decide which way to go.  From a statistical risk stand point, people under 35 are at lower risk with the biological options (homograft, Ross, valve paring) since the risk of redo surgery 10  - 20 years is typically lower than the cummulative risks of anticoagulation therapy (blood clot or hemmorage).  There is also the lifestyle issues for younger patients that favor the biological alternatives.  If the thought of another surgery is just too overwelming, then the mechanical valve may be the answer - But having a mechanical valve is no guarentee that you will not need  to have it replaced at some time in the future.  Good luck, these are some of my thoughts for what they are worth.

[Ben, Ohio to Todd W.]

The "David Procedure" is just repair?
E-mail me (***@****) I would liek some information.