Ross Procedure Renaissance Widens Options for Patients

Cardiothoracic surgeons at Massachusetts General Hospital offer the Ross procedure (also known as the pulmonary autograft) to patients needing aortic valve replacement. The complex procedure has seen varying levels of adoption over the last 60 years. Still, Jordan Bloom, MD, MPH, cardiac surgeon at Mass General and Harvard Medical School assistant professor of Surgery, considers the surgery an ideal option for many young patients with aortic valve disease. The procedure is applicable to patients with prior heart valve surgeries, endocarditis, and other complexities with excellent results.

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Dr. Bloom specializes in treating adult patients who were born with congenital heart disease. Since joining the Mass General staff in July of 2022, he and his former senior partner, cardiac surgeon Duke Cameron, MD, have performed more than 25 Ross procedures.

"The Ross isn't an option many people talk about. But it is the only operation for aortic stenosis that data suggest may restore an age-matched normal life expectancy to a patient after the operation," says Dr. Bloom.

The Ross Renaissance: Resurgence of Interest

The first Ross procedure was done in 1967 by British surgeon Donald Ross. It replaces a diseased aortic valve with the patient's own pulmonary valve (autograft). A donated valve (homograft) is used to replace the pulmonary valve. Surgeons then reimplant the pulmonary valve in the aortic position and attach the coronary arteries onto the autograft.

The procedure's complexity and some early unfavorable outcomes resulted in varying adoption rates among cardiothoracic surgeons. Critics argued that the procedure turned a one-valve problem into a two-valve problem. "In the late 1990s, it gained popularity but fell out of favor quickly. Over the last 20 years, it has primarily been done in high volume at pediatric centers," Dr. Bloom says. But a small group of surgeons continued to perform the procedure on adults, improving on technique and outcomes.

"These surgeons stuck with the Ross procedure and have published many impressive studies. These data have been coming out consistently since 2015, and the data around survival is promising. You see it now being discussed in journals, at international meetings, and on social media," Dr. Bloom explains. "We are seeing a renaissance for the Ross."

Despite these encouraging results, there are only a small number of high-volume centers in the world that perform the Ross procedure in adults. "I think Mass General and places like it are the perfect environments for operations like the Ross and corresponding research," Dr. Bloom notes. "This operation can't be done just anywhere. It must be done responsibly, carefully, and with strict clinical and scientific supervision."

Ross Procedure Associated With Longer Survival and Lower Reintervention

Patients with a diseased aortic valve more commonly undergo aortic valve replacement (AVR), which replaces the diseased valve with a biological or mechanical aortic valve, both of which come with significant tradeoffs. Mechanical valves typically last a lifetime but require lifelong anticoagulation therapy, which carries risks. Biological valves don't require anticoagulation therapy, but patients usually need a replacement valve in 10 to 20 years. "We know that younger patients have shorter durability with a biological valve," Dr. Bloom adds. Neither solution is perfect. "We would like to avoid thinking about patients with aortic valve disease as having to choose between anticoagulation or reoperation."

These imperfect options are the inspiration for performing the more complex Ross operation, which does not require anticoagulation and appears more durable than a tissue prosthesis. Dr. Bloom points to studies that indicate lower long-term survival of patients after AVR than the general population but more hopeful late results after the Ross. This may in part be due to a selection bias toward lower-risk, younger patients undergoing the Ross or—as its proponents suggest—because of better hemodynamic performance and lower postoperative gradients. Reintervention rates are promising as well.

"There are 45- and 50-year Ross survivors that have not needed reintervention. A recent 20-year data set showed that patients who underwent a Ross have about a 0.7% per year chance of needing reintervention on either the autograft or homograft. Projecting this same rate out to 20 years would suggest a 28% chance of needing reintervention, which is significantly better than any biologic AVR series."

Finally, reintervention on either the autograft or homograft after Ross is now expected to be performed using a transcatheter technique, thereby avoiding needing reoperative surgery.

Giving Patients Aortic Valve Repair Options

Dr. Bloom says growing knowledge of the benefits of the Ross is leading more patients to ask for the procedure over AVR. His patients needing aortic valve repair are offered both options if they are good candidates for either surgery.

Though surgeons typically use the Ross in younger patients as they have the most to gain in terms of reintervention and are most likely to be free of significant comorbidities that complicate the procedure, Dr. Bloom says there is no defined chronological age limit. "The Ross is for 'young patients with aortic valve disease,' but both are general terms, and that's intentional. There is no hard age limit, and it can be used to address multiple aortic valve problems. Essentially, any patient who needs to have their aortic valve replaced can be considered for the Ross."

Ross Procedure Modifications and Research

Surgeons at Mass General use several advanced modifications to optimize the Ross procedure. "The modifications are things we've learned from other people that do this operation a lot and have published incredibly durable results," says Dr. Bloom.

Procedure modifications include:

• Decellularized homograft: Before surgery, the donor pulmonary valve is stripped of all donor cells, which is thought to create less of an immunologic response and increase the durability of the homograft
• External Support: Surgeons reinforce the ventriculo-aortic junction and the sinotubular junction to prevent dilation. Dr. Bloom says he supports the Ross on patients with risk factors for dilation, including those with:
  • A bicuspid aortic valve that starts with a dilated aorta
  • A bicuspid aortic valve that starts with a dilated aortic annulus
  • Primary aortic regurgitation

• Patient care: For the first six months following surgery, the care team strictly monitors the patient's blood pressure and prescribes medications to control it if necessary. NSAIDs are also prescribed for six months to help the body adjust to the homograft and prevent early rejection

Dr. Bloom and fellow physician-researchers are planning to use single-cell sequencing to gain insights into failed and successful Ross procedures. They will collect blood and tissue samples from patients during follow-up.

"We want to see at the cellular level what happens when a Ross fails or succeeds. Typically, the homograft fails, so we hope to understand the immunological mechanism of failure. We may then be able to identify a medication that could control or prevent that response," Dr. Bloom says.

Dr. Bloom is also leading an international study hoping to define best practices for the Ross procedure and has founded a national registry to drive research and quality improvement.

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