The Ross Operation

A demanding cardiac surgical procedure that yields excellent results for young patients

An editorial to accompany the article: “The Ross Operation in Young Patients—a Single-Center, Long-Term Follow-Up Study” by Dr. Markus Liebrich et al. in this issue of Deutsches Ärzteblatt International

When it comes to the Ross operation, one often hears from heart surgeons and cardiologists that it is: “Too complex, too difficult, and too fraught with complications. There are easier alternatives.” Quite true—it is much easier and faster to perform a simple aortic valve replacement, either surgically or, more recently, in an interventional setting as transcatheter aortic valve implantation (TAVI). In comparison, the elaborate Ross operation, which turns a single-valve procedure into a two-valve procedure, appears incomparably more difficult and complex.

Explanatory note

In the Ross operation, the stenotic or insufficient aortic valve is replaced with the patient’s own pulmonary valve, which is in turn replaced with a human donor valve (homograft). This technique was first used by Donald Ross in London in 1967, since there were no suitable valve prostheses at that time.

Opponents of the Ross operation point out that very good mechanical as well as biological (porcine or bovine) valve prostheses are available today.

Long-term results

But how do things look for patients in the long term? Mechanical valve prostheses require lifelong anticoagulation with a vitamin K antagonist (for example, phenprocoumon), which is associated with a bleeding risk of 0.13%/patient year and a reduced life expectancy compared to the age- and sex-matched general population (1). Biological prostheses are subject to varying degrees of structural degeneration, which occurs more rapidly in particular in young patients compared to older patients, making reoperations necessary with the corresponding cumulative lifetime risk (2). With the Ross operation, the patient’s own valve is transferred to the aortic position. It is important to emphasize that the valve does not degenerate—when used in children, it grows with the patient, and it does not require anticoagulation.

In this issue, the working group at the Herzzentrum Stuttgart presents its long-term results in 795 patients following the Ross operation: Survival rates at 5, 10, 15, and 20 years were 97%, 96%, 92%, and 86%, respectively; freedom from reoperation on the auto- and homograft/RV-PA conduit was 96%, 91%, 81%, and 70% for these time periods (3).

Data as good as in the international Ross registry

The data presented in the study by Liebrich et al. are as good as those in the international Ross registry: 95.4% survival at 10 years, 79.4% at 20 years, and rates of freedom from reoperation of 95.4% at 5 years, 84.7% at 15 years, and 77.6% at 20 years (4). Conventional porcine or bovine bioprostheses do not achieve such good results when implanted in young patients (2). Thus, the alternative to the Ross operation is the implantation of a mechanical aortic valve and lifelong use of phenprocoumon.

To date, there are only sparse (disappointing) data on the use of new oral anticoagulants in patients with mechanical valves (5): In a prospective trial with 252 patients, the use of dabigatran following mechanical valve replacement (compared to the use of vitamin K antagonists) was associated with an increased risk of bleeding and thromboembolic events and can therefore not be recommended. Indeed, the trial was terminated prematurely. Thus, for the time being, strict anticoagulation remains mandatory following mechanical aortic valve replacement.

Promising results from the ARISE study

The question arises as to why, when the aortic valve needs to be replaced, the homograft cannot be implanted in the aortic position. In this regard, Horke et al. presented the 5-year data from the ARISE trial in a single-arm multicenter study. The use of decellularized homografts in the aortic position in young patients (median age of 30.4 years) was deemed promising. The survival rate was 97.9% and the rate of freedom from reoperation 93.5% (6). However, unlike for the Ross operation, there are no long-term data for this as yet.

For use in highly specialized centers only

In our view, therefore, the following applies until further notice: For young patients, there is no better alternative, and in some cases for children no alternative at all, to the Ross operation for high-grade aortic valve stenosis or regurgitation. As is so often the case, the principle that only a certain minimum quantity can yield sufficient quality also applies here.

Therefore, the undeniably surgically demanding Ross operation should only be performed by very experienced surgeons in highly specialized centers. In their hands, however, patients can expect excellent long-term results and, in the ideal case, assume that their life expectancy will not differ from that of the normal population.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Translated from the original German by Christine Rye.

Corresponding author
Prof. Dr. med. Sebastian Michel
LMU Klinikum, Herzchirurgische Klinik und Poliklinik
Campus Großhadern
Marchioninistraße 15
81377 München, Germany

Cite this as:
Michel S, Hagl C: The Ross operation—a demanding cardiac surgical procedure that yields excellent results for young patients.
Dtsch Arztebl Int 2024; 121: 764–5. DOI: 10.3238/arztebl.m2024.0229

References

1. Korteland NM, Etnel JRG, Arabkhani B, et al.: Mechanical aortic valve replacement in non-elderly adults: meta-analysis and microsimulation. Eur Heart J 2017; 38: 3370–7.

2. Etnel JRG, Huygens SA, Grashuis P, et al.: Bioprosthetic aortic valve replacement in nonelderly adults: a systematic review, meta-analysis, microsimulation. Circ Cardiovasc Qual Outcomes 2019; 12: e005481.

3. Liebrich M, Dingemann C, Roser D, et al.: The Ross operation in young patients—a single-center, long-term follow-up study. Dtsch Arztebl Int 2024; 121: 766–72.

4. Aboud A, Charitos EI, Fujita B, et al.: Long-term outcomes of patients undergoing the ross procedure. J Am Coll Cardiol 2021; 77: 1412–22.

5. Eikelboom JW, Connolly SJ, Brueckmann M, et al.: Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med 26; 369: 1206–14.

6. Horke A, Tudorache I, Laufer G, et al.: Five-year results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement—the ARISE Study and ARISE Registry Data. Eur J Cardiothorac Surg 2024; 65: ezae121.