Surgeon Q&A: Inspecting the Pulmonary Valve During the Ross Procedure
Written By: Allison DeMajistre, BSN, RN, CCRN
Medical Expert: William Brinkman, MD, Aortic Valve Surgeon, Baylor Scott & White The Heart Hospital – Plano, Plano, Texas
Reviewed By: Adam Pick, Patient Advocate, Author & Website Founder
Published: May 16, 2025
The Ross Procedure, which has seen a resurgence in recent years due to reports of better long-term outcomes and surgical refinements, replaces the aortic valve with the patient’s pulmonary valve. A homograft, or donor valve, is then used in its place. That said, the Ross Procedure is a very complicated “two-valve” operation.
Surgeons perform extensive pre-procedure testing to ensure patients are suitable candidates before entering the operating room. Specific tests evaluate the pulmonary valve to determine if that valve will be durable enough to withstand the high pressures in the aortic valve position. Although testing is comprehensive, what happens if the surgeon can’t use the pulmonary valve once the procedure has begun?
I met with Dr. William Brinkman to gain insight into this critical aspect of the Ross Procedure while we were at the Society of Thoracic Surgeons Conference. Dr. Brinkman is a leading aortic valve surgeon at Baylor Scott & White The Heart Hospital-Plano in Plano, Texas who specializes in the Ross Procedure.
Inspecting the Pulmonary Valve
Here are key insights shared by Dr. Brinkman:
- When doing a Ross Procedure, is it often, seldom, or rare that a pulmonary valve won’t fit or work in the aortic position? “I would say it is seldom,” said Dr. Brinkman. “But it happens. We do a lot of testing beforehand, like an echocardiogram and a cardiac CT to look at the size of the pulmonary valve and the aortic annulus. We also try to look at the leaflets. We look at how the pulmonary valve is working. But even with that, in our series, I would say about a 10 percent chance.”
- Fenestrations, or holes in the pulmonary valve leaflets, may be problematic for long-term durability. “When we look down at those leaflets, we might see some fenestrations, or holes, that don’t affect its function in a low-pressure system like the pulmonary position,” stated Dr. Brinkman. But if you moved it into the high-pressure system, we worry it wouldn’t last long. In that situation, we may bail on the Ross Procedure. I would say it happens about 10 percent of the time.”
- It is a “game-time” decision that can’t be made by looking at imaging but rather in the operating room. Dr. Brinkman said, “Because these leaflets are very thin, it’s almost like a flag in the wind, and you need to take a close look at it. The best CT scans and echocardiogram still can’t quite give us that resolution yet.”
Thank you, Dr. Brinkman and Baylor Scott & White!
On behalf of all the patients in our community, thank you, Dr. William Brinkman, for everything you and your team are doing at Baylor Scott & White in Plano, Texas!
Related links:
- Ross Procedure Research Alert: Durability & Reoperations with Dr. Bill Brinkman
- New Ross Procedure Patient Education Center
- Surgeon Q&A: Treating Bicuspid Aortic Valves & Aortic Aneurysms
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. Brinkman below.
Written by Adam Pick
- Patient & Website Founder
Video Transcript:
Adam Pick: Hi everybody. It’s Adam with HeartValveSurgery.com and we’re in Los Angeles, California at the Society of Thoracic Surgeons Conference. I’m thrilled to be joined by Dr. Bill Brinkman, who is a leading aortic valve surgeon at Baylor Scott White The Heart Hospital – Plano, in Plano, Texas. Dr Brinkman. It is great to see you again and thanks for being with me at STS.
Dr. Bill Brinkman: Yes, sir.
Adam Pick: We’ve known each other for 10 years plus. We always talk about is the Ross procedure. I’m a patient. You are a superstar Ross Procedure surgeon. One of the questions what I remember is when you’re going in for a Ross operation, my surgeon said to me, “Adam, I’m going to do my best to give you a Ross procedure. But there’s a possibility that the pulmonary valve may not be best suited for the aortic position.”
I’m curious to know when you’re doing your Ross operations is it often, seldom or rare that a pulmonary valve just won’t fit or work in the aortic position?
Dr. Bill Brinkman: I would say it is seldom. But, it happens. We do a lot of testing beforehand, like an echocardiogram and a cardiac CT to look at the size of the pulmonary valve and the aortic valve annulus.
We also try to look at the leaflets. We look at how the pulmonary valve is working. But even with that, there’s about a, I would say in our series, about a 10% chance. When we look down at those leaflets, you might see some, what we call fenestrations, or holes, in the leaflets that don’t affect its function in a low pressure system.
Like the pulmonary position, but if you moved it into the high-pressure system, we worry that it wouldn’t last long. Then in that situation, we may bail on the Ross Procedure. So, I’d say it’s about 10 percent of the time.
Adam Pick: Got it. And this is really, it sounds like it is a game time decision, right? You are, when you say I’m looking at it, you’re, it’s no longer about imaging. You are in the operating room, correct?
Dr. Bill Brinkman: Yeah, because these leaflets are very thin. It’s almost like a flag in the wind and you need to take a good close look at it. The best CT scans and the best echocardiogram still can’t quite give us that resolution yet.
Adam Pick: Great. Well, Dr. Brinkman, as always, thanks for everything you and your team are doing at Baylor Scott and White The Heart Hospital in Plano, Texas.
Dr. Bill Brinkman: Thank you.
