Ross Procedure Reoperations: What Should Patients Know?

Written By: Adam Pick, Patient Advocate, Author & Website Founder

Medical Expert: Michael Ibrahim, MD, Cardiac Surgeon at Penn Medicine

Published: November 16, 2022

The Ross Procedure is an advanced form of aortic valve replacement for patients with aortic valve disease.  During this unique operation, developed by Dr. Donald Ross in the 1960s, the patient’s defective aortic valve is replaced by the patient’s own pulmonary valve.  Then, a homograft (donated human tissue) is placed in the patient’s vacant pulmonary valve position.

As we have learned, the Ross Procedure is the only form of aortic valve replacement that provides patients the advantages of living tissue within the aortic position.  We have also learned that the Ross Procedure can provide patients excellent long-term results.  (On a personal note, I had the Ross Procedure performed 17 years ago. Since then, I have had no problems.)

Given the Ross Procedure benefits, patients are still curious to know what happens if one or both of the replaced valves fail. For example, Joe recently asked me, “Is it more common for the aortic valve or pulmonary valve to fail?” and “If the aortic or pulmonary valve fails, can a transcatheter valve replace the failing valve without an open-heart procedure?”

To answer these important questions, I interviewed Dr. Michael Ibrahim, a leading cardiac surgeon and Ross Procedure specialist from Penn Medicine in Philadelphia, Pennsylvania.  During his career, Dr. Ibrahim has performed over 1,000 heart valve procedures including many Ross Procedures.

 

Key Learnings About Ross Procedure Reoperations

Here are important learnings from Dr. Ibrahim about Ross Procedure reoperations:

  • A critical advantage of the Ross Procedure is that it restores normal life survival. “The benefit of the Ross operation is that it’s the only operation which provides a living sophisticated heart valve that can do all of the amazing things that your normal, natural valve can do,” states Dr. Ibrahim. “This has been shown to really have a bearing on clinical outcome. It’s the only operation for aortic valve disease compared to mechanical or tissue valves that restores normal life survival.”

 

Dr. Michael Ibrahim - Penn Medicine Heart Surgeon
Dr. Michael Ibrahim

 

  • If a Ross Procedure, which is a two-valve operation fails, the aortic valve is more likely to fail than the pulmonary valve. Doctor Ibrahim states, “If you should require a reoperation on one of the heart valves that’s been operated on, it’s likely to be the aortic valve, the new aortic valve, but the chances of that are low. Within 15 years after the operation, only about 30% of patients will require a reoperation. On the pulmonary valve, if the operation is done correctly in the way that it was originally described, less than 2% of patients will require a reoperation on the right side of the heart.”
  • To replace a failing aortic or pulmonary valve after a Ross Procedure, it is possible to receive a non-invasive transcatheter valve replacement that does not require an incision to the patient’s chest or ribs or the use of the lung-machine. “Transcatheter valve replacement through the groin is now the primary way of replacing failing Ross pulmonary valves of the right side if that happens, which is rare,” states Dr. Ibrahim. “On the left side of the heart, on the aortic side, it can also be used, but one of the things is that sometimes Ross patients are so young that when they come to reoperation, if that occurs, it may not be the best option for them, but it is certainly one option.”

Thanks Dr. Ibrahim & Penn Medicine!

Many thanks to Dr. Michael Ibrahim for taking time away from his very busy practice to share these fantastic insights about Ross Procedure reoperations with our patient community. In addition, I’d like to thank Penn Medicine for taking care of so many patients in our community including Patricia Garcia, Michael Casey, and Theresa Gusset.

Keep on tickin!
Adam

P.S. For the deaf and hard of hearing members of our community, I have provided a written transcript of my interview with Dr. Ibrahim below.

Written by Adam Pick
- Patient & Website Founder

Adam Pick, Heart Valve Patient Advocate

Adam Pick is a heart valve patient and author of The Patient's Guide To Heart Valve Surgery. In 2006, Adam founded HeartValveSurgery.com to educate and empower patients. This award-winning website has helped over 10 million people fight heart valve disease. Adam has been featured by the American Heart Association and Medical News Today.

Adam Pick is a heart valve patient and author of The Patient's Guide To Heart Valve Surgery. In 2006, Adam founded HeartValveSurgery.com to educate and empower patients. This award-winning website has helped over 10 million people fight heart valve disease. Adam has been featured by the American Heart Association and Medical News Today.

Video Transcript:

Adam: Hi, everybody. It’s Adam with heartvalvesurgery.com. This is a special surgeon question and answer session all about Ross procedure reoperations. I am thrilled to be joined by Dr. Michael Ibrahim who is the leading cardiac surgeon at Penn Medicine in Philadelphia, Pennsylvania. During his extraordinary career, Dr. Ibrahim has performed over 3,000 cardiac procedures with more than 2,000 involving some form of heart valve repair or heart valve replacement. Dr. Ibrahim, it is great to see you again. Thanks for being with us today.

Dr. Ibrahim: Thanks for having me, Adam. It’s great to be here and with your patients on heartvalvesurgery.com.

Adam: Yeah, Dr. Ibrahim, we’re answering not one but two questions from Joe. They’re all about Ross procedure reoperations. Here’s the first one. Joe asks, “Hi, Adam. I’m considering the Ross procedure. As this operation is a double valve replacement, if a reoperation is needed in the future, do you know which valve tends to fail first, the aortic or the pulmonary?”

Dr. Ibrahim: Great question. Let’s take a step back for a moment and review what the Ross operation actually does. It is an operation for aortic valve disease, for aortic stenosis, and aortic regurgitation. What it does is it takes the mirror image heart valve in your heart, the pulmonary valve, and it places it in the aortic position, so getting rid of your old aortic valve, and in the pulmonary position, a homograft, which is a valve from a patient that’s passed away, is placed in the human natural valve.

Really, the benefit of the Ross operation is that it’s the only operation which provides a living sophisticated heart valve that can do all of the amazing things that your normal, natural valve can do. This has been shown to really have a bearing on clinical outcome. It’s the only operation for aortic valve disease compared to mechanical or tissue valves that restores normal life survival.

If you should require a reoperation on one of the heart valves that’s been operated on, it’s likely to be the aortic valve, the new aortic valve, but the chances of that are low. Within 15 years after the operation, only about 30% of patients will require a reoperation. On the pulmonary valve, if the operation is done correctly in the way that it was originally described, less than 2% of patients will require a reoperation on the right side of the heart.

Adam: Dr. Ibrahim, that is fascinating and encouraging data about the long-term benefits of the Ross procedure, but Joe has a very important follow-up question I’m sure lots of patients are wondering. If the Ross procedure does fail, can the defective aortic or pulmonary valve be replaced using a noninvasive TAVR?

Dr. Ibrahim: The short answer is yes. Transcatheter valve replacement through the groin is now the primary way of replacing failing Ross pulmonary valves of the right side if that happens, which is rare. On the left side of the heart, on the aortic side, it can also be used, but one of the things is that sometimes Ross patients are so young that when they come to reoperation, if that occurs, it may not be the best option for them, but it is certainly one option.

Adam: Dr. Ibrahim, I love how you brought in not just the fact that there’s a potential for a transcatheter valve replacement for the aortic or failing pulmonary valve, but the idea of the long-term management of valve disease, shared decision making for younger patients because a SAVR, a surgical aortic valve replacement, may be best for that patient, if I understood you right. Is that correct?

Dr. Ibrahim: I totally agree. I think it’s all about giving patients the correct information, making sure that they’re comfortable, they’re seeing an expert who can offer all options, and then making a decision that respects the patient’s preferences and wishes for their life.

Adam: Dr. Ibrahim, I hope that helped Joe. I know it helped me. I can’t thank you enough for taking time away from your very busy practice there are Penn Medicine in Philadelphia, Pennsylvania and sharing all this great insight with our community. Thanks for being here today.

Dr. Ibrahim: Thank you.

Adam: Hi, everybody. It’s Adam. I hope you enjoyed that video. Don’t forget you can always subscribe to our YouTube channel, watch the next two educational videos coming up on your screen, or click the blue button to visit heartvalvesurgery.com.