The Ross Operation: Treatment of Choice for Aortic Valve Disease in Children and Young Adults

1 also called the pulmonary autograft procedure, involves replacement of the diseased aortic valve with the patient’s own pulmonary valve (autograft) and implantation of a biological valve (homograft) in the pulmonary position. It was first described and pioneered by Mr. Donald Ross in 1967 in London. The procedure was popularised in the 1980s when homografts became widely available on both sides of the Atlantic. In its new aortic position the patient’s pulmonary valve remains viable, does not calcify, has the potential to grow, does not require anticoagulation and is rarely associated with histological degeneration. Perhaps not surprisingly, the Ross procedure was not initially adopted widely. The operation is longer and more complex, commits both the patient and the surgeon to double valve surgery, while the early morbidity and mortality during the learning curve were substantial. However, improved surgical techniques, better myocardial protection during cardiopulmonary bypass and the availability of commercially prepared homografts have stimulated an increase in interest and led to the accumulation of –by now– a much wider experience with the Ross procedure. Reoperation for neo-aortic valve regurgitation has been the major complication following the Ross procedure. Failure of the pulmonary autograft has been attributable to technical errors at the time of operation, progressive aortic regurgitation due to inadequate coaptation of the leaflets, or pulmonary autograft-to-aortic annulus mismatch. Transaortic pressure gradients after the Ross procedure are negligible, and clearly better than for bioprostheses or mechanical valves. Ten and 20 years after the procedure 85% and 61% of hospital survivors from the pioneer series were alive, with 88% and 75% freedom from autograft replacement and 89% and 80% freedom from replacement of the pulmonary homograft, respectively. These results compare favourably to any other bioprosthetic valve replacement. More recently, a reduced incidence of neo-aortic valve regurgitation and reoperation at mid-term follow-up has been reported with the implantation of the pulmonary valve and the pulmonary artery as an anatomical unit (root method) compared to the sub-coronary technique. Furthermore, Elkins and colleagues described the insertion of the pulmonary cylinder using the aortic root inclusion technique. Fixation of the autograft root to the relatively dense collagen structure of the aortic annulus and its implantation within the native aorta seems to prevent distortion of the commissures and –by providing external support– minimises dilatation of the pulmonary autograft. Subsequently, Pacifico et al utilised bovine pericardial circumferen-