The Ross Procedure, also known as the pulmonary autograft procedure, is an innovative operation utilized in the treatment of aortic valve disease. Primarily reserved for the treatment of young and active patients, the procedure involves using the patient's own pulmonary valve (the "autograft") as a replacement for a diseased aortic valve, and in turn replacing the pulmonary valve with a donor tissue valve ("homograft"). As is shown in the animated demonstration movie, the pulmonary valve is identical in form, size and function to the aortic valve, thus making it an ideal substitute.

The method. The Ross Procedure is an open-heart procedure performed on bypass (that is, with the assistance of the heart-lung machine). After the heart is stopped, the surgeon explores the aortic and pulmonary valves to determine the feasibility of performing the Ross Procedure. By all accounts the Ross Procedure must be performed with the utmost degree of training and skill to achieve an architecturally perfect valve in the aortic position. If it appears upon exploration that this cannot be achieved given the valve pathology, the skilled surgeon will opt for simply replacing the aortic valve with a homograft.

When the decision is made to proceed, the diseased aortic valve (and root, if necessary) is excised and discarded. The harvested pulmonary valve is then implanted with techniques similar to a standard homograft implantation. A strip of pericardium (or Teflon) may be harvested and sewn into the upper portion of the autograft, to aid in controlling the elasticity of the aortic root. The pulmonary valve position is then filled with a biologic tissue or donor valve.

Significant advantages over standard aortic valve replacement. The search for the perfect aortic valve replacement continues, as limitations continue to plague both mechanical and bioprosthetic valves. The autograft's lifespan, resistance to infection, and excellent hemodynamic performance make it an ideal option for young and/or active patients with aortic valve disease.

Optimal hemodyamics. The primary advantage inherent in the procedure is the pulmonary valve's ability to mimic the intrinsic structural characteristics of the native aortic valve, resulting in optimal hemodynamic function. This, together with its proven long-term integrity as a living tissue valve, has made the Ross Procedure an attractive alternative for young and/or active individuals with aortic valve disease.

No blood-thinning medication. Because the autograft is living tissue native to the patient, there is no chance of graft rejection. There is also no need for long-term anti-coagulation (blood thinning) therapy-which comes as welcome news for patients who will continue to rely on their active lifestyles for years to come.

Longer valve life with valve growth. The pulmonary autograft also demonstrates the potential for growth, which has proven to be a distinct advantage for children and young adults. The long-term valve survival rate of the pulmonary autograft (upwards of 30 years) clearly exceeds that of homografts, bioprosthetic and mechanical valves (less than 10 years).

What about the donor valve in the pulmonary position? The pulmonary position is far better suited to homograft replacement than the aortic position, for two reasons. One, a smaller pressure gradient means the new homograft will not have to work as hard as it would in the aortic position. And two, any clots that may form on and break away from the replacement homograft will be filtered through the lungs, never reaching the general bloodstream.

Risks. Many see the impact of a two-valve operation as unnecessary and drastic when only one valve is diseased. Indeed, there is an obvious, inherent invasiveness that must be recognized and appreciated before the decision is made to proceed.

Technical complexity. What's more, the Ross is technically more complex than a standard aortic valve replacement. Success in creating an architecturally perfect new aortic valve demands a high level of training, patience and skill. First and foremost, this requires an operator (surgeon) with knowledge, experience and a commitment to understanding and performing this operation.

Longer duration of bypass. This consideration for structural perfection simply requires more intraoperative clock-time than does a standard replacement. The patient is on bypass (the heart stopped) for a longer period, which represents some additional risk. This additional time, however, is a basic requirement to obtain an architecturally perfect result, i.e. structural perfection.

General results. The encouraging 20-year results Mr. Ross published in 1998, outlining his personal series from 1967 to 1986, renewed interest in the procedure and confirmed that the pulmonary valve provided superior durability in the aortic position. During the past decade, the Ross Procedure has emerged as the operation of choice for young individuals with aortic valve disease not subject to repair, thanks in part to positive results from individual surgeons' patient series.