EDITORIAL

ROSS PROCEDURES FOR THE DEVELOPING COUNTRIES

Amer Chaikhouni, MD, FACC
Al-Salam Hospital, Aleppo, Syria

References

   In 1967, Mr. Donald N. Ross(1) reported a new concept in valve operations: The use of the pulmonary valve as an autograft for aortic or mitral valve replacement.  However, Ross procedure is usually used in literature to describe the replacement of the aortic valve with a pulmonary autograft and simultaneous replacement of the pulmonary valve with a homograft.  Over the past few decades, some cardiac surgeons introduced technical variations.  However, surgeons did not apply Ross procedure frequently in aortic valve replacement, especially in adult patients.  The STS registry in USA for aortic valve patients younger than 60 years of age shows that during 1990 - 2000, Ross procedure was used in only 5% of aortic valve replacement operations.

   Few surgeons adopted the Ross procedure because of its difficulty, complexity, and possible long-term complications.  In this issue of Heart Views, the review by Pettersson and Grimm of Cleveland clinic reports their results in that institution. 33% of their Ross procedure patients developed 3+ aortic insufficiency at 5 years of follow up, and 16% re-operations rate for AI and/or RVOT obstruction.  Other problems encountered were aortic autograft dilatation, and pulmonary allograft stenosis. The review also reports on the experience of other institutions such as the Netherland registry(2), with up to 2.6% operative mortality. Despite all that, Ross procedure does have some clear advantages, particularly in pediatric cardiac patients. Al-Halees et.al.(3) consider Ross procedure as the operation of choice for congenital aortic valve disease.

   Advantages of Ross procedure include: Potential for growth of the aortic autograft, superior hemodynamics and good exercise tolerance, low risk of thromboembolism, no need for long term anticoagulation, and very good results in the treatment of severe recurrent aortic valve endocarditis.  To avoid the use of anticoagulants is of particular importance in some patients, such as young female patients, and those with bleeding peptic ulcer disease or other conditions that make anticoagulation hazardous with possible bleeding complications.

   In the developing countries, safe use of anticoagulants is complicated because of lack of adequate medical facilities for careful follow up, poor education, low awareness, and difficult economic conditions.  These problems make the use of mechanical valves hazardous in developing countries with increased possibility of thromboembolic and hemorrhagic complications. The social pressure on young females to have more children is also high.  This gives Ross procedure possible special advantages in the developing countries.

   Dr. Kabbani in Damascus, Syria, expanded the applications of Ross procedure to the use of the pulmonary autograft for mitral valve replacement, as suggested by Mr. Ross in 1967.  Dr. Kabbani used the Top Hat technique, originally developed by Ross and M.H Yacoub, and reported initial good results in 43 patients(4).  This experience has now increased to more than 80 patients with good short term results (verbal communication). 

   Interestingly, young patients with the original Ross procedure for aortic valve replacement, and those with the modified Kabbani-Ross (Ross II) procedure for mitral valve replacement, are still at risk for developing rheumatic valve disease.  These patients should be protected with Penicillin prophylaxis, and treated as indicated. 

   Ross procedure is a challenge for cardiac surgeons, and it’s use for aortic or mitral valve replacement should be considered as a good alternative, and probably as a preferred option in some patients, particularly in the developing countries.¨

References

1.  Ross DN. : Replacement of aortic and mitral valves with a pulmonary autograft. Lancet.      1967;2:956-8. 

2.  Thakkenberg J J; Dossche KM, Hazekamp MG, Nijveld A. et.al. Dutch Ross Study Group.      Report of the Dutch experience with the Ross procedure in 343 patients. Eur J. cardiothoracic      Surg. 2002; 22:70-7. 

3.  Al-Halees Z, Pieters F., Qadoura F, Shahid M et.al : the Ross procedure is the procedure of      choice for congenital aortic valve disease. J. Thorac Cardiovasc Surg. 2002 ;123:437-41. 

4.  Kabbani SS, Jamil H, Hammoud A, Nabhani F et.al.: Use of the pulmonary autograft for mitral      valve replacement: short and medium term experience. Eur J. Cardiothorac Surg. 2001;      20:257-61.

Correspondence to Dr. Amer Chaikhouni, Chief of Cardiac Surgery, Al-Salam Hospital, Aleppo, Syria.