Undoing What's Been Done: The Ross Reversal Procedure


The Ross procedure was introduced by Donald N. Ross in 1967 to treat aortic valve disease as an alternative to an aortic homograft, particularly for pediatric patients, with the autograft demonstrating improved durability and growth potential when compared to a homograft.1,2 Long-term studies have demonstrated that the Ross procedure has several advantages compared to other aortic valve replacement options, including superior quality of life, freedom from lifelong anticoagulation, reduced incidence of stroke and bleeding events and similar survival to a matched general population.3,4 Nonetheless, one notable complication of the Ross procedure, identified by Tirone E. David in 2000,5 is progressive dilation of the autograft root, precipitating insufficiency and valve failure, with up to 25% of patients requiring reoperation within 10 years.6

Impetus for Innovating This Procedure and Challenges

There are several surgical options for patients with autograft dilation or aortic insufficiency after the Ross procedure: valve-sparing reimplantation (David procedure), composite graft (Bentall procedure) and allograft root replacement. Valve-sparing reimplantation can be an ideal option for patients with a well-functioning pulmonary allograft, minimal autograft dilation and symmetric aortic cusps. On the other hand, in patients with valve degeneration or asymmetric cusps or surrounding tissue, a valve-sparing operation can be less feasible, and the durability of the valve is questionable. One study found 17% of patients who underwent the valve-sparing operation had severe aortic insufficiency within three years of reoperation, while a large European multi-center study found 24% of patients who underwent valve-sparing operation due to autograft failure required reintervention within 8 years.7,8 Furthermore, reoperation can risk the loss of a second native valve, potentially leading to a two-valve disease in patient with only aortic valve disease and patient disappointment.

Current State

Enter the Ross reversal operation, a procedure pioneered by Gosta B. Pettersson in 2006 that involves excision of the autograft and reimplantation of the autograft into its native pulmonary position, rescuing the pulmonary autograft (Figure 1). Following autograft excision, the cusps are fashioned for reimplantation into the smaller pulmonary position, repairing potential cusp asymmetry or dilation (Figure 2). The aortic root is replaced with a mechanical, bio-prosthetic or allograft, based on patient preference.9 To date, Dr. Pettersson has performed the Ross reversal operation on 30 patients, determined to be non-ideal candidates for valve-sparing reimplantation, with no intraoperative mortality and a mean postoperative stay of 7.2 days. Indications for reoperation were variable among the patients, with all patients reporting neo-aortic root aneurysm formation and/or severe neo-aortic insufficiency and 18 patients reporting moderate or severe concurrent pulmonary allograft dysfunction or degeneration. Among the 30 patients, 21 received a composite mechanical aortic root, five received a bio-prosthetic valve, and four received an allograft.10,11

Figure 1: Autograft is excised and reimplanted into native pulmonary position

Figure 1

Figure 2: Excised autograft is fashion for reimplantation into native pulmonary position

Figure 2

Outcomes of patients undergoing Ross reversal have been encouraging, with no patient mortality and no patients requiring reoperation during mean clinical follow up of 4.5 ± 3.5 years. No patients have reported symptomatology related to pulmonary valve dysfunction.11 Hemodynamic function of the right ventricle, as assessed by echocardiography, has also improved; there were significant reductions in peak pulmonary gradient from 29 ± 20 to 14 ± 9 (p = 0.0002) and right ventricular systolic pressure from 42 ± 14 to 32 ± 10 (p = 0.0064), with preserved function of the right ventricle as assessed by fractional area of change.12 This follow-up data supports the durability of the reimplanted autograft and the reliability of the Ross reversal operation, though further follow-up evaluation is necessary to better understand the durability of this valve.

Recently, the Ross reversal operation has inspired discussion regarding whether the operation reliably leaves the patients with one-valve disease or converts a patient's two-valve disease into another two-valve disease. In an editorial commentary, Leonard N. Girardi points out that the answer to this question hinges upon the yet unknown long-term function of the pulmonary autograft.13 Only time will be able to answer this question; however, it is encouraging to note that function of the pulmonary autograft in patients undergoing Ross reversal has remained intact thus far.

Future Vision

Moving forward, continued monitoring of pulmonary autograft function and freedom from reoperation will play a key role in informing the outcomes of the Ross reversal operation. Up to this point, studies have been limited to a single surgeon at a single clinical center, due, in part, to the technically challenging nature of the operation, and hopefully in the future, a greater number of surgeons will consider the utility of the Ross reversal operation for patients with autograft dysfunction after the Ross operation.


  1. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 1967;2:956-8.
  2. Ross D, Jackson M, Davies J. Pulmonary autograft aortic valve replacement: long-term results. J Card Surg 1991;6:529-33.
  3. El-Hamamsy I, Eryigit Z, Stevens LM, et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 2010;376:524-31.
  4. Mazine A, David TE, Rao V, et al. Long-term outcomes of the Ross procedure versus mechanical aortic valve replacement: propensity-matched cohort study. Circulation 2016;134:576-85.
  5. David TE, Omran A, Ivanov J, et al. Dilation of the pulmonary autograft after the Ross procedure. J Thorac Cardiovasc Surg 2000;119:210-20.
  6. Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Davila-Roman VG. The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg 2004;78:773-81.
  7. de Kerchove L, Rubay J, Pasquet A, et al. Ross operation in the adult: long-term outcomes after root replacement and inclusion techniques. Ann Thorac Surg 2009;87:95-102.
  8. de Kerchove L, Boodhwani M, Etienne PY, et al. Preservation of the pulmonary autograft after failure of the Ross procedure. Eur J Cardiothorac Surg 2010;38:326-32.
  9. Flynn M, Little SG, Blackstone EH, Pettersson GB. Reversing the Ross operation: a new reoperation option for autograft failure. J Thorac Cardiovasc Surg 2007;133:1645-7.
  10. Pattersson GB, Subramanian S, Flynn M, et al. Reoperations after the Ross procedure in adults: towards autograft-sparing/Ross reversal. J Heart Valve Dis 2011;20:425-32.
  11. Hussain ST, Majdalany DS, Dunn A, et al. Early and mid-term results of autograft rescue by Ross reversal: a one-valve disease need not become two-valve disease. J Thorac Cardiovasc Surg 2018;155:562-72.
  12. DunnA, Majdalany DS, Hussain ST, Blackstone EH, Pettersson GB. Echocardiographic evaluation of patients at follow-up after Ross reversal operation due to autograft dysfunction. 2018.
  13. Girardi LN. Ross reversal: one to one, one to two, or two to two? J Thorac Cardiovasc Surg 2018;155:573-4.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Valvular Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Echocardiography/Ultrasound

Keywords: Pediatrics, Heart Defects, Congenital, Heart Valve Diseases, Aortic Valve, Allografts, Reoperation, Pulmonary Valve, Heart Ventricles, Follow-Up Studies, Dilatation, Autografts, Blood Pressure, Reproducibility of Results, Aortic Valve Insufficiency, Heart Valve Prosthesis, Dilatation, Pathologic, Echocardiography, Replantation, Stroke, Surgeons, Aneurysm

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