Feasibility of the ross procedure: its relationship with the bicuspid aortic valve

The feasibility of the Ross procedure, and which patients benefit most from its performance, have not yet been fully established. The study aim was to analyze the relationship between the etiology of aortic valve disease, the feasibility of performing the Ross procedure, and late pulmonary autograft performance.

Between June 1995 and June 2001, 117 patients (77 males, 40 females; mean age 37+/-12 years) underwent the Ross procedure at the authors' institution. Of these patients, 53 (45.3%) had severe aortic stenosis, 53 (45.3%) had significant aortic insufficiency, four (3.4%) had active endocarditis, two (1.7%) had subaortic stenosis, and five (4.3%) had prosthesis dysfunction. Eighty-one patients (69%) had a bicuspid aortic valve. Pulmonary autograft dysfunction was defined as regurgitation grade > or =2, as registered by Doppler echocardiography.

The Ross procedure was successful in 100 patients (85.5%); hospital mortality was 2.6% (n = 3). The procedure was not feasible in 17 patients (14.5%); of these, seven had bicuspid pulmonary valve, six had >3 mm multiple pulmonary valve fenestrations, three had severe pulmonary insufficiency, and one patient had dissection-related pulmonary valve injury. Twelve of 16 patients presenting with pulmonary valve defects had bicuspid aortic valve (p = 0.04). At six-year follow up, the probability of not requiring reoperation was 93% (confidence interval 86-100%). During follow up (30+/-14 months; range: 2-72 months), six patients presented with grade 2 pulmonary autograft insufficiency, three with grade 3, and two with grade 4. Six of the latter 11 patients (p = 0.03) had a history of bicuspid aortic valve with aortic regurgitation. Freedom from autograft dysfunction was 87% (confidence interval 82-92%). Patients with bicuspid aortic valve and aortic valve regurgitation had a higher tendency towards autograft dysfunction than those with bicuspid aortic valve and aortic stenosis (65% versus 100%, p = 0.004).

The feasibility of performing the Ross procedure is high, unless there is presence of bicuspid aortic valve. Patients with bicuspid aortic valve and a history of aortic insufficiency tend to develop moderate autograft dysfunction during long-term follow up.