Penn Aorta Center Co-director Nimesh Desai, MD, PhD, outlines the role of the Ross procedure for young patients with aortic valve disease, including how the modern Ross procedure is different, the evolution of Penn’s program, and who is a candidate.
Related Links: See Dr. Desai's physician profile thank you and appreciate the opportunity to talk about some emerging and really interesting concepts that were now applying to the management of the aortic valve disease and younger patients in particular. So when we look at aortic valve disease and younger patients, um I think our thinking is really changing away from What we've been thinking about the last 10 years or 15 years in the tavern era, about risk, low risk, intermediate risk, high risk into life expectancy. So what what decisions do you make about a patient who needs to live another 20 years, 25 years or 40 years. Um and I think we're really entering this era of age related decision making and integrating into it. All these new treatment algorithms we have like a valve and valve taverns and some emerging areas where we're looking at mechanical valve replacements with a lot of the the classic ways that we think about aortic valve replacement, especially younger patients are really evolving. Um One of the things I think we are really developing a good understanding of now though is that our current ways of treating the aortic valve with our traditional prostheses, mechanical or tissue really are deficient. That this is data that shows from the journal by one of our former fellows that shows that In fact when you look at patients who are younger typically if you're less than 55 you do better with mechanical, older than 55 tissue is a good alternative. But the actual mortality of these patients at 10-15 years was almost 30%. So we're not, you know, we can't tell these people that fixing their aortic valve is gonna kind of bring them back to normal life expectancy again. And it's not, these are really uh inadequate solutions we have. And what we really need is a more physiologic solution. And this is where the ross procedure, which is a traditionally more thought of as more of a congenital heart surgery operation is something that we are applying more and more to uh to uh younger adults and younger patients with aortic valve disease. It's a procedure where we take the patient's pullman IQ routes to the pulmonary artery and valve and put it in the aortic positions are moving from the right side, the low pressure side to the left side, high pressure side. Uh and that's their new aortic valve and route. Uh and then we use a cryo preserved home a graft categoric tissue to replace the palm on a group and demonic valve, Low pressure. We think that it can be durable in that situation. Um potential advantages of the ross incredibly natural gradients. It is a natural valve. There's nothing obstructive about it. Very good durability and we'll go into that in a little bit. It's a living valve. It has cells in it. They're still alive. Um and it functions exactly what our valves do, including, you know, getting larger during sisterly when we're exercising. So they actually give young patients a really good exercise capacity. So, these are some of the reasons that we become much more interested in the ross operation, but there are some potential problems with the ross. It's a more complex surgery, I think in the hands of experienced surgeons who do a lot of root replacement surgery, it's it's something that certainly within our wheelhouse. Um but it does potentially create two valve problems instead of one. So, you have a pulmonary holograph and you moved the actual pulmonary valve to the aortic position. Um You have, you can have attrition of the pulmonary home, a graph that can happen either at the conduit level, which is actually quite common um that that can calcify and narrow or at the value level and the autographed itself can dilate. This is the, you know, you're taking up something designed to have a systolic pressure in the thirties and putting it in the systemic circulation. It can stretch and dilate Over time as well. But inexperienced Hans overall the rate of re intervention in a Ross operation on either side is less than 15% at 15 years. And that's using techniques, I think we've actually gotten better with now than in the past. Um So what is different about the modern ross? Why are we interested in doing it again all of a sudden? Well, all the potential failure modes of the ross have been one way or another being addressed, we figured out ways to eliminate all of the platonic root issues. So, we used to leave a lot of pulmonary artery in there, a lot of harmonic muscle in there. All gone. We just leave the valve and just a little bit of the sinuses. We can reinforce everything at the annual level and at the scientifically junction. So there really isn't a lot of room for this thing to grow. And we have a very strongly supported uh harmonic root in their autographed in there. We also use a D cell arised pulmonary home a graft. We put big ones in. These, tend to not to notice, they tend not to have immune reactions. We also use Nsaids post op and really strictly controlled people's blood pressure. So when you put that pulmonary autographed in the high pressure scenario um that you're not loading it unnecessarily causing destruction, dialect cause most of that actually happens in the first 3 to 6 months. Um We started a ross program about a year ago, just over a year ago now and we've been very active, very busy with it. Um And and um you know, part of it was because we learned better implant techniques. We had better homa graphs. We have ways of intervening on the palm on the valve without opening the patient up again with Taber like technology and most importantly, the ross really is the only aortic valve therapy that can return a person to the normal life expectancy. This is brand new data from new york state and California state, which shows that you see the black dotted lines at the bottom of the general population. And the Ross operation patients have the identical 15 year survival rate, mechanical and tissue valves not the same much worse. Um We put together a really strong program of anesthesia, cardiology specialist, surgeon. So only a couple of us do this um and advanced ICU services to make sure that we can manage these patients well. And we follow them very closely in our postoperative clinics and today we're offering this operation to people who are under 60 typically have non repairable pathology. Again, if we can repair the valve that's almost always better and we will repair. But stenosis patients, endocarditis patients failed bio of er patients. All patients are candidates for the ross. Um And we will extend it to aneurysm patients as well as long as they don't have connective tissue disease like Marfan syndrome. And this is just an example of one of these cases where a young person had a congenital bicuspid aortic valve, had a tissue valve done in their twenties because they didn't want to take anti coagulation. Came back with a failed bio prosthetic valve at seven years and this is our harmonic autograph being put in here. Um This is a pretty complicated case of redux, There was a bit of an aneurysm which we replaced as well. Um And that's the final product and really nice, perfectly functioning, natural looking valve, which is absolutely great. Uh And so we're excited to offer this procedure to our younger patients. And I look forward to the discussion um about the management of a rebel disease in this group. Thank you.