Pioneer. On July 24th, 1962, Mr. Donald Ross of England's National Heart Hospital performed the world's first transplant of an aortic valve with a valve from a human donor. Results from the operation's infancy steadily improved, and over the next four years Mr. Ross replaced more than 100 aortic valves with human donor valves.

Later known as homograft replacement, the procedure has become one of the standard methods for aortic valve disease treatment. Mechanical valves, animal tissue valves, and surgical reconstruction have also emerged as popular options.

Like many open-heart procedures of the day, the risks were many. The willingness of surgeons like Mr. Ross and his colleagues to consider and accept these risks led to many advances in cardiac treatment. Thanks to them, what was high-risk then has now come closer to routine.

The search for a better valve. In the late 1960s, the acceptable restrictions of homograft replacement-a lack of long-term durability and consequent leakage, difficulty in size matching, supply and storage restrictions-prompted Drs. Lower and Shumway at Stanford Hospital to pose the question: why not use the patient's own pulmonary valve to replace the diseased aortic valve?

Ross took note of Lower and Shumway's animal experiments, and considered the limitations the homograft valve places on the active patient's post-operative activity levels -- the child with 60 or 70 years of life ahead of him, the woman who plans to bear children, the athlete whose livelihood would be severely hampered by blood-thinning medication. It was then that he suggested trying the procedure in humans -- a bold proposition that led to a new paradigm in aortic valve treatment: the pulmonary autograft, or Ross Procedure.

More than 30 years later, hemodynamic and functional data show that the patient's pulmonary valve provides the closest substitute to the normal performance of the aortic valve. While the Ross Procedure is not suited to all aortic valve disease patients, the data also demonstrates that, when performed correctly, it is the best possible surgery option for aortic valve disease in most patients who want a highly active post-operative lifestyle.

In theory...The theoretical arguments for this innovation were never disputed. Mother Nature would guard against any form of tissue rejection in the new autograft. The pulmonary valve's size and tri-leaflet architecture would approximate the aortic valve better than any of the current options.

And, although the donor pulmonary position would require a homograft valve, the risks associated with homografts would be passed from the aortic position to the pulmonary one, where a low-pressure gradient and a less critical circulatory role make homograft replacement far less risky. The risks of infection and stroke would also be decreased significantly. All of which would translate to long-term freedom from reoperations and complications.

So far, of course, this was all theory. It took practice to prove it.

Theory into practice. Mr. Ross first performed his procedure at Guys Hospital on June 8, 1967 -- with a perfect result. Now, more than thirty years later, hundreds of surgeons from around the world are learning and performing the Ross Procedure. The late 1980s saw Dr. Ronald Elkins (University of Oklahoma) and Dr. Lorenzo Gonzalez-Lavin (Deborah Heart-Lung Institute of New Jersey) as the first in the U.S. to acquire the techniques and begin practicing the procedure. Every year several international colloquia focus on new Ross techniques, general outcomes, and the feasibility of furthering application of the operation into developing nations.

Outcomes. Currently, RossRegistry.com is the most complete database of Ross Procedure outcomes, dating back to Mr. Ross' first patient in 1967, in addition to what the Registry has termed "modern day" outcomes (from 1988 on). The encouraging 20-year results that 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. The positive results from individual surgeons' patient series are also responsible for this increase in the popularity of the procedure.