The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement

Abstract

The Ross procedure is gaining recognition as a significant option for aortic valve replacement (AVR), and is particularly beneficial in specific patient groups. Although categorized as a class IIb recommendation in the 2020 American College of Cardiology (ACC)/American Heart Association (AHA), and the European Society of Cardiology (ESC) management guidelines on valvular heart disease, recent studies bolster its credibility. Research, including a propensity-matched study, underlines the Ross procedure's association with enhanced long-term survival and reduced adverse valve-related events compared to other AVR types. This positions the Ross procedure as a primary option for AVR in young and middle-aged adults within specialized centers, and potentially the only choice for children and infants requiring AVR. This review meticulously examines the Ross procedure, covering historical perspectives, surgical techniques, imaging, and outcomes, including hemodynamic performance and quality of life, especially focusing on pediatric and young adult patients. It explores contemporary techniques and innovations like minimally invasive approaches and tissue engineering, underscoring ongoing research and future directions. A summarization of comparative studies and meta-analyses reiterates the Ross procedure's superior long-term outcomes, valve durability, and preservation of the left ventricular function, accentuating the crucial role of patient selection and risk stratification, and pinpointing areas for future research.

Keywords: Ross procedure; adverse valve-related events; aortic valve replacement; contemporary surgical techniques and innovations; prosthetic aortic valve; surgical techniques; tissue engineering; valve hemodynamics; valve imaging; valvular heart disease.

Figure 1

Transthoracic echocardiography Parasternal short axis view; Panel (A): Degenerative homograft cusps (yellow arrow, diastolic phase); Panel (B): Degenerative homograft cusps (yellow arrow, systolic phase); Panel (C): color Doppler showing the regurgitation originating from the right pulmonary artery suggestive of severe regurgitation; Abbreviations: RVOT: Right ventricular outflow track, RA: Right atrium, AoV: Aortic valve, MPA: Main trunk of pulmonary artery, RPA: Right main branch of pulmonary artery.

Figure 2

Panel (A) Parasternal short-axis (PSAX) view at aortic valve level short-axis (PSAX) view showing severe homograft stenosis with degenerative homograft cusps (yellow arrow) RVOT and MPA. Panel (B); color Doppler demonstrating systolic flow acceleration starting at the level of pulmonic homograft (yellow arrow) indicating pulmonic valve stenosis (PS). Panel (C); Continuous-flow (CW) Doppler across the pulmonic valve showing severe PS with peak and mean gradients of 69 and 42 mmHg, respectively; Abbreviations: AoV: aortic valve, RVOT: right ventricle out-flow tract, MPA: main pulmonary artery.

Figure 3

Cardiac magnetic resonance (CMR) with oblique sagittal stack cine cuts at different level showing pulmonic homograft stenosis. Green arrow showing defacing (showing significant stenosis); Abbreviations: PV: pulmonary valve, RVOT: right ventricular outflow track, RA: right atrium. RV: right ventricle, LA: left atrium.

Figure 4

This figure presents a systematic review encompassing three distinct patient populations from studies reporting outcomes in adult patients aged between 18 and 55 years who have undergone the Ross procedure [34], bioprosthetic aortic valve replacement [35], and mechanical aortic valve replacement [36]. Panel (A) illustrates the aggregated early mortality rates, represented on the Y-axis, across different cohorts subjected to the three aforementioned surgical procedures. Panel (B) displays the aggregated annual late mortality rates as percentages. Panel (C) delineates the lifetime risk percentages for re-intervention in the Ross procedure, with separate data for the autograft in the aortic position and right ventricular outflow tract (RVOT) surgical interventions, as well as for bioprosthetic and mechanical aortic valve replacements. Panel (D) involves pooled data input into a microsimulation model, estimating the life expectancy, in years, of a 45-year-old patient following different aortic valve replacement surgeries. These estimates are compared (highlighted in red) with the projected life expectancy, post-45 years, of the general population that has not undergone any surgical interventions.