Young and middle-aged patients weighing their options for an aortic valve replacement are often drawn to the Ross Procedure. Although it is a technically complex operation requiring an expert surgeon practicing in a high-volume center, it has the potential for long-term, viable aortic valve replacement without the need for lifelong anticoagulation. In fact, new research published in the Journal of the American Medicine Association shows that the survival of Ross Procedure patients mirrors the general population. This means that Ross Procedure patients had the same life expectancy as people who did not have aortic valve disease.

So you know, I had a Ross Procedure nearly 20 years ago with great success. I’ve had no reoperation and no further intervention.  My heart is doing great. However, many patients just receiving the news that they need an aortic valve replacement may not have heard of the Ross Procedure (or know very little about it).

I recently met with Dr. Richard Kim, the Director of Pediatric and Congenital Cardiac Surgery at Cedars-Sinai in Los Angeles, California, to learn more about the Ross Procedure and the importance of finding a surgeon with the proper expertise to operate.

Key Learnings About Ross Procedure Surgeon Selection

Here are important insights shared by Dr. Kim:

• Can you explain the Ross Procedure for patients who are not familiar with it? “The Ross Procedure is for patients who have severe aortic valve disease and need to have their aortic valve replaced,” Dr. Kim said. “Generally speaking, it’s for younger patients who are 50 or younger or want to maintain an active lifestyle.”

• The Ross Procedure is a very complex operation. Dr. Kim explained that the Ross Procedure is significantly more challenging and takes longer to perform. He said that the surgeon removes the patient’s pulmonary valve from another part of the heart and moves it to the aortic position. The surgeon then replaces the patient’s pulmonary valve with an off-the-shelf replacement.

• Pressures within the heart impact valve function and durability. “Because of the differences in the pressures in the heart, this combination of replacements has the potential to last significantly longer than your standard aortic valve replacement,” said Dr. Kim. Dr. Kim explained that the aortic valve is under tremendous stress, particularly for younger patients. “The bioprosthetic valve commonly used generally only lasts ten years or less,” he said. “Mechanical valves require blood thinners, and it’s something that most people find difficult to manage. It’s also important that we use the native pulmonary valve in a high-stress position. Your own native tissue can adapt over time, so it’s not unusual for this valve to last 20 years or more. Most importantly, patients who undergo a successful Ross Procedure have the potential for the longest life expectancy of any patient undergoing any aortic valve replacement.”

• How do patients know if the surgeon they’re talking to is an experienced Ross Procedure surgeon? “Like all things, experience matters,” said Dr. Kim. “Particularly for the Ross Procedure, which is quite a complicated operation. The Ross has several nuances and potential pitfalls, and you have to do enough to understand how to manage each problem. For instance, if the valve is small, do you have to increase the size of the valve? How do you know if the valve is going to work? Is the valve particularly problematic? Is there a way to change your technique to save a valve that is not quite as good as you would like?” Dr. Kim noted that he and several of his colleagues recently published a paper looking at all the Ross Procedures done in children under 18 across the United States for over 20 years. More than half of the procedures were done on kids of adult size.

• Kim made some conclusions about how the children’s study may compare to adults having a Ross Procedure. “Although a direct comparison to adults can’t really be made, I think some of the conclusions hold true,” he said. “The first conclusion is that across 120 different sites, the overall mortality in adult-age Ross patients was less than one percent. So you can have excellent outcomes across the United States at many different centers. The second conclusion is that Ross Centers and these studies averaged approximately six Ross Procedures per year at the highest volume. So, very few centers are doing more than that every year, and I think that holds for adults, also. Myself, I do about 10 to 15 Ross Procedures per year. So, who’s to say if you wanted to know what the absolute number is? Is it 5, 10, 25, 100?” Dr. Kim explained that asking how many Ross Procedures a surgeon or center performs may not be the right question. “I think you need to discuss with your surgeon and ask whether or not they’re truly comfortable with the procedure.”

• What is the youngest patient that Dr. Kim operated on with the Ross Procedure? “The very youngest patients of the Ross Procedure are usually patients we are trying to salvage a valve. For instance, if a child is born with a congenital problem with a valve, their first procedure is usually a balloon valvotomy, which doesn’t work so well, and we end up having to do the Ross Procedure. So, the youngest patient I’ve done a Ross Procedure on is just a few days old.”

• Given all you know, what is your advice for a patient or parent who thinks the Ross Procedure could be the right therapy for them? “I think the most important thing is for parents or patients to have an open, frank conversation with their surgeon,” said Dr. Kim. “Ask the surgeon the questions that matter to you the most. Ask yourself whether or not you believe your surgeon can do the procedures you want them to do or that they are proposing to do. And finally, take a real good measure of whether or not your surgeon is taking the time to address your concerns and questions.”

Thanks Dr. Kim and Cedars-Sinai!

From everyone in the HeartValveSurgery.com community, many thanks to Dr. Richard Kim, for sharing your knowledge and insight into the Ross Procedure and how to select the right surgeon. We also want to thank Cedars-Sinai Medical Center for continuing to care for our heart valve patients!

Related Links:

• Pediatric Heart Valve Surgery: Surgeon Insights with Dr. Richard Kim
• Weight Gain After Heart Surgery: What Should Patients Know?

Keep on tickin,
Adam

P.S. For the deaf and hard-of-hearing members of our patient community, we have provided a written transcript of our interview with Dr. Kim below.