n a Ross procedure, a surgeon removes the abnormal aortic valve. The surgeon then replaces it with the child's own pulmonary valve. The surgeon uses a valve from a cadaver donor (conduit) to replace the pulmonary valve.

1. Manu Jacob
Perfusionist
ROSS PROCEDURE

2. The Ross procedure also known as the switch
procedure or pulmonary autograft procedure,
is a cardiac surgery in which a diseased aortic
valve is replaced with the patient's own
pulmonary valve. This is followed by the
replacement of the pulmonary valve with a
pulmonary allograft.

3. Diagram of the principle of the Ross procedure. The pulmonary artery root is explanted
(A) and implanted (as autograft) in the aortic annulus by a ''total root replacement'' technique
(B). The right ventricular outflow tract is reconstructed using the pulmonary allograft.

4. During the Ross procedure, it is critical to know the
anatomy of the left main coronary artery and its take-off. In
addition, the surgeon should know the course of the left
coronary artery, its proximal septal branches and their
relationship to the aortic root and the right ventricular
outflow tract. In addition, when harvesting the pulmonary
autograft the surgeon should have an appreciation of the
subpulmonary conal musculature to facilitate the dissection.
Finally, if the left ventricular outflow tract needs
enlargement (Ross Konno procedure) the surgeon must be
familiar with the location of the conduction system

5. Indications
• Aortic valve disease in children with congenital aortic stenosis (most common
indication)
• Females of childbearing age wanting to bear children in the future with bicuspid
aortic valve and small aortic annulus
• Some variations of left ventricular outflow obstructive disease
• Native or prosthetic valve endocarditis depending on the extent of disease
• Some forms of adult aortic regurgitation with a dilated aorta
• Severe forms of aortic valve disease not amenable to repair

6. Contraindications
• Absolute contraindications :
• Marfan syndrome
• Pulmonary valve disease
• Immune disorders like lupus
• Advanced three-vessel coronary artery disease
• Significant mitral valve disease
• Relative contraindication: (due to a higher risk of autograft dysfunction)
• Rheumatic valve disease
• Dysplastic dilated aortic root

7. • Prior to the procedure, an echo should assess the aortic valve, the left ventricular
outflow tract obstruction, and any other cardiac abnormality. The pulmonary valve
should also be assessed for stenosis or regurgitation. Echocardiography also allows
for sizing the aortic and pulmonary annulus. If the aortic annulus is smaller than the
pulmonary annulus by 2-3 mm, the surgeon may be required to perform an aortic
root enlargement procedure.
• The Ross procedure is performed via a median sternotomy under cardiopulmonary
bypass.
• The postoperative course is the same as for any other open-heart surgery patients.
Patients are usually weaned off the ventilator the same night and extubated in the
morning.

8. Complications
• Aortic insufficiency
• Right ventricular outlet obstruction
• Aortic autograft dilatation
• Pulmonary allograft stenosis
• Cerebrovascular event
• Myocardial infarction/ischemia
• Hemorrhage
• Respiratory distress
• Drug reactions
• Blood reactions
• Arrhythmias
• Infection
• Death