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The Ross Procedure for Aortic Valve Replacement in Younger and Middle-aged Adults

Cardiac surgeons at the Penn Heart and Vascular Center are performing the Ross procedure for aortic valve replacement (AVR) in young and middle-aged adults with aortic valve disease.

The Ross procedure involves the removal of the diseased aortic valve (shown) and its replacement with the native pulmonary valve, which is then replaced with a homograft.

AVR is the standard approach to insufficiency and stenosis of the aortic valve in older individuals, but presents unique challenges in younger and middle-aged persons.

The options for AVR include mechanical valve substitutes, bioprosthetic valves, aortic valve homografts, and the Ross procedure (pulmonary autografts). For older persons (above 70 years old), the survival advantage between mechanical and bioprosthetic valves is insignificant, simplifying choice. But because younger and middle-aged individuals have greater hemodynamic demands for the aortic valve and greater life expectancy, the choice of an AV substitute necessarily involves then elements of valve durability, the avoidance of complications leading to reoperation, and longterm quality of life.

Ultimately, only the Ross procedure can restore normal life survival in patients less than 70 years of age. [1]

Bioprosthetic and Mechanical Valves

The findings of recent studies demonstrate excess mortality in young and middle-aged adults implanted with mechanical or bioprosthetic valves in inverse proportion to patient age at surgery. [2, 3] What this mean is that simple aortic valve replacement does not restore life expectancy. This finding is thought to be the result of higher functional demand and longer exposure to valve-related complications in these populations.

In addition:

  • Mechanical valves require lifelong anticoagulation, and thus the potential for hemorrhage and thromboembolism in persons whose lifestyles or personal choices conflict with adherence to these agents' strict dietary and scheduling guidelines. Mechanical valves have been shown to substantially increase the risk of thrombogenic events in young women during pregnancy, for example. [4]
  • Bioprosthetic valves have been linked to structural deterioration and a significant risk for reoperation. [5]

Homografts, Autografts

  • Homograft concerns include poor durability, limited availability, and increased complexity of reoperation. [6]
  • Pulmonary autografts: Dearth of availability for the Ross procedure in the United States is a principal concern for younger and middle-aged adult patients.*

*For a comprehensive overview of the Ross procedure, the concerns engendering its decline, and its recent revival, see Ibrahim M, Spelde AE, Carter TI, et al. The Ross Operation in the Adult: What, Why, and When? Journal of Cardiothoracic and VascularAnesthesia 2018;32:1885 – 1891.

The Ross Procedure | The Ideal Procedure for Younger and Middle-Aged Adults?

The Ross procedure involves the replacement of the aortic valve with a pulmonary autograft and the implantation of a homograft at the pulmonary position. In so doing, the Ross takes advantage of the tricuspid similarity of the aortic and pulmonary valves and the biologically sophisticated structure and function of a living valve.

Introduced in the late 1960s by innovator Donald Ross, the procedure lost ground in the 1990s with the introduction of simpler, more accessible alternatives, and the appearance of reports about valve durability and other complications. As recently as 2014, the Ross accounted for fewer than 0.1% of all AVRs in the United States [7]; it is today performed only at highly specialized medical centers in the United States — including Penn Medicine in Philadelphia.

Advantages of the Ross Procedure

Recent evidence from longterm studies suggests that the Ross procedure can restore normal life expectancy to young and middle-aged adults with AV disease and that the procedure offers hemodynamic performance similar to that found in age-matched cohorts in the general population. [8,9]

Among other advantages, the Ross allows young women with AV disease to have children. [10] Moreover, several investigations have demonstrated that the Ross procedure can be performed with an operative risk equivalent to that of conventional AVR in high-volume surgical centers. As evidenced by higher scores on both the physical and psychological health subscales of the short-form health survey, in addition, patients who undergo the Ross procedure enjoy enhanced quality of life compared with those who undergo mechanical AVR. [11]

For more information about the Ross procedure at Penn Cardiac Surgery, please contact: Dr. Ibrahim at 215-662-9595

Case Study

At age 51, Mr. D, an active amateur sportsman, was referred to Dr. Ibrahim at Penn Cardiac Surgery for a consultation regarding the Ross procedure following the failure of a bioprosthetic valve implanted 8 years before at another institution. Having educated himself on his condition, Mr. D recognized that another bioprosthetic valve might fail early, and had no interest in the lifelong anticoagulation required of a mechanical valve. He had previously explored the option of the Ross procedure with a surgeon in his community, who declined, citing anomalies in his coronary arteries and his second operation.

At Penn, a transthoracic echocardiogram and careful assessment of pulmonary valve function, the ascending aorta, and pulmonary annular diameter, Mr. D was deemed a suitable candidate for the Ross.

Under general anesthesia, Mr. D had a median sternotomy and a standard cardiopulmonary bypass The aorta was opened, his old artificial aortic valve excised and the annulus inspected. The coronary arteries arising at the aortic sinuses were then separated with buttons of aortic wall tissue and the remainder of the sinus segments resected as in a conventional root replacement.

The pulmonary artery was next mobilized and a transverse incision made. Inspection of the pulmonary valve confirmed that it was tricuspid, without fenestrations and free of atherosclerotic plaque. Dissection of the pulmonary artery then continued proximally to the pulmonic root, which was then harvested 2 to 3 mm below the pulmonary valve annulus.

Following implantation of the autograft in the aortic position (a subannular orientation within the left ventricular outflow tract), the coronary buttons were reimplanted in the autograft root below the sinotubular junction. The autograft was then trimmed to allow a few millimeters above the level of the commissures, and the distal suture line completed. At this point, the resected pulmonary valve was replaced with a slightly oversized homograft, taking care to avoid injury to the left coronary artery system. The distal pulmonary artery anastomosis was then completed and standard de-airing procedures were performed.

Mr. D was discharged to home after four days in the hospital. During the next six months, his postoperative management included tight blood pressure control (systolic BP

About the Ross Procedure at Penn Cardiac Surgery

The Penn Heart and Vascular Center performs the most heart valve surgeries in Pennsylvania, New Jersey and Delaware, delivering high success and low complication rates in every age group. The Penn Heart Surgery Program is recognized for its expertise in surgeries for aortic disease, arrhythmias, congenital and inherited heart disease, heart valve disorders, and transplantation, as well as for innovations in cardiac surgery.

Performing the Ross Procedure at the Penn Heart and Vascular Center

Michael Ibrahim, MD, PhD

Nimesh D. Desai, MD, PhD


Penn Presbyterian Medical Center
Heart & Vascular Pavilion, 2nd Floor
51 N. 39th Street
Philadelphia, PA 19104
215 662 9595

Hospital of the University of Pennsylvania - Pavilion
1 Convention Avenue
Philadelphia, PA 19104


  1. David TE, David C, Woo A, et al. The Ross procedure: outcomes at 20 years. J Thorac Cardiovasc Surg 2014;147:85-93.
  2. Bouhout I, Stevens LM, Mazine A, Poirier N, Cartier R, Demers P, et al. Longterm outcomes after elective isolated mechanical aortic valve replacement in young adults. J Thorac Cardiovasc Surg. 2014;148:1341-6.e1.
  3. Kvidal P, Bergstrom R, Horte LG, Stahle E. Observed and relative survival after aortic valve replacement. J Am Coll Cardiol. 2000;35:747-756.
  4. Bouhout I, Poirier N, Mazine A, Dore A, Mercier LA, Leduc L, et al. Cardiac, obstetric, and fetal outcomes during pregnancy after biological or mechanical aortic valve replacement. Can J Cardiol. 2014;30:801-807.
  5. Puvimanasinghe JP, Steyerberg EW, Takkenberg JJ, Eijkemans MJ, van Herwerden LA, Bogers AJ, et al. Prognosis after aortic valve replacement with a bioprosthesis: predictions based on meta-analysis and microsimulation. Circulation. 2001;103:1535-1541.
  6. Ouzounian M, Mazine A, David TE. The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults. J Thorac Cardiovasc Surg 2017;154:778-782.
  7. Reece TB, Welke KF, O'Brien S, et al. Rethinking the ross procedure in adults. Ann Thorac Surg 2014;97:175-181.
  8. El-Hamamsy I, Eryigit Z, Stevens LM, et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 2010;376:524 – 531.
  9. Pibarot P, Dumesnil JG, Briand M, Laforest I, Cartier P. Hemodynamic performance during maximum exercise in adult patients with the Ross operation and comparison with normal controls and patients with aortic bioprostheses. Am J Cardiol 2000;86:982 – 988.
  10. Hung L, Rahimtoola SH. Prosthetic heart valves and pregnancy. Circulation 2003;107: 1240 – 1246.
  11. Zacek P, Holubec T, Vobornik M, et al. Quality of life after aortic valve repair is similar to Ross patients and superior to mechanical valve replacement: a cross-sectional study. BMC Cardiovasc Disord 2016;16:63.

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