ROSS PROCEDURE and Aortic root enlargement - ASKED SURGEON A QUESTION - SEE RESPONSE

[themalteser]

Dear All,

I would like to share a response I had from a surgeon in regards to the Ross Procedure and Ao Root enlargement - please find below:

P.S. I can't understand why the life expectancy, as mentioned below, is lower than the average if using Mechanical Valve.....

"If the aortic root is mild to moderately enlarged, we can perform a standard Ross procedure, associated with a reduction procedure on your aortic root, to receive the pulmonary autograft valve. If the aortic root is severely enlarged, we can still perform a Ross procedure, providing the rest of your heart and coronary arteries are within normal limits. Also, this latter method, where the pulmonary autograft valve is inserted within a "Valsalva" Dacron graft, will need to be further explained to you face to face. It is difficult to explain via email. Also, I am not sure what age you are. The more radical procedure to insert the pulmonary autograft inside a Dacron graft, is really only suitable for patients under the age of 50 years.

Life expectancy after aortic valve replacement is shown to be normal after the Ross procedure, although less than in an age and sex matched population, if a mechanical valve is used."

 

[markp66]

Life expectancy is probably lower with a mechanical because of warfarin which carries a 1-2% risk of bleeding or stroke due to blood clotting on the valve. Good INR management minimises this risk. Endocarditis is also more of a risk with an artificial valve. However, my surgeon told me I could expect a relatively normal life expectancy with a mech valve and that it potentially could last 50+ years. However, life expectancy is a calculation and on paper because there are more things that can go wrong it is bound to be lower. Remember life expectancy for an average person is around 78 but there are MANY people who live until 90+.

Ross procedure is a great option for children because the valve grows with the body. However, many surgeons today would argue that it has very few benefits over a standard tissue valve because at some point this will need replacing which could be 8-20 years.. You also have the downside that you will then have a 2 valve problem. There is an article on the Cleveland website which mentions there is absolutely no benefit of the Ross after a certain age. However, as usual and with everything in life surgeons will probably disagree. My surgeon said that the Ross fails more often with people who have a bicuspid valve, especially if the root/ valve is small. Just look at Arnold swarzenegger. His valve lasted a few days and the it needed replacing with a standard tissue valve and he also has the problem of a replaced pulmonary valve which will probably need replacing.

Unfortunately there are lots of options, none of them great but all better than the current situation. Bare in mind at the complication rate is very low with mechanical valves in younger patients.

Hopefully you won't need to make this decision for a few years yet!

 

[scott.eitman]

I read that differently than you. I believe that it is saying that the life expentancy is lower than if a mechanical valve is used. Meaning the Mechanical has a longer life expectancy. Either way, it is written without much clarity there.

 

[themalteser]

RESPONSE FROM SURGEON

My data with the Ross procedure, when performed for aortic valve stenosis shows that the 15 year freedom from re-operation on either the aortic or pulmonary valve is 97%. The freedom from re-operation for most mechanical valves is in the 95% to 97% range at 15 years. Some mechanical valves do require replacement because of infection, paravalvular leak (when the valve does not heal in normally to the aortic annulus), as well as occasional cases of valve thrombosis. Also, occasionally tissue can grow in under the mechanical valve and cause obstruction, thus requiring later re-operation.

In addition, people with a mechanical valve then have to go onto permanent anticoagulation with Warfarin. This reduces the risk of a stroke from approximately 10% a year (if Warfarin was not used with a mechanical valve) to approximately 1% per year. However, there is also a 1% to 2% risk of major bleeding per year with a mechanical valve.

Thus, whilst mechanical valves are durable, the durability of the Ross procedure for aortic valve stenosis has also been found to be equivalent, when utilising the inclusion cylinder method (which is my preferred method), and survival after surgery is better when a Ross procedure is performed

 

[markp66]

Those stats are great. The Ross seems very good when done in the right hands, lots of centres have stopped doing it but maybe this is because of lack of experience. You surgeon sounds like his success rate is high. At some point you would probably need both valves replacing and if they failed at different times it could be argued that this could mean. 2/3 morecops down the line. Does anyone know if there are patients who have had a 30 year freedom from operation with the Ross? There are many for mechanical valves. One great thing about the Ross is that you have it done and forget about the problem for years. Although I have no problem taking warfarin I'm definitely more aware of the fact I've had heart surgery (taking a pill everyday and hearing a slight ticking of the valve).

As I said before, hopefully you won't need to make a decision for a few years yet. Surgery and options are only going to improve.

 

[themalteser]

Thanks Mark for your reply, I've replied to your aother post at the same time regarding mechanical valves.

The statistics seems excellent. I am not sure about Ross procedure though, because of having 2 valves to worry about, although, a study by professor sir Magdi Yacoub ( one of the top surgeons - Yacoub procedure) also suggests that the Ross procedure has better outcomes.

Will be nice to know how many are free from re-op as well.

 

[markp66]

Also, just to let you know I had a modified be tall procedure with a mech valve. There are a few studies online that say the survival rate is comparable with an age-sex matched population with well managed INR.

 

[markp66]

Here is one of the studies re the Bentall procedure and that it gives normal LE compared to controlled population. The other isn't online but my surgeon said the same thing, maybe they were form his studies. One thing this does mention is that a Bentall op with a tissue valve is ok in a young patient because it can easily be replaced. Mech valves are slightly harder although you would expect them to be replaced (think there is less chance with Bentall procedure..). Its hard to take any study that seriously because so many vary. The Ross procedure seems to have good and bad stats all over the place and so does every other valve, procedure etc etc. As my surgeon said, if there was one technique far superior to another then everyone would be getting it done! The fact that every patient acts differently, age, sex, lifestyle all add up to make valve choice, procedure very complicated.

The study is below.

http://ats.ctsnetjournals.org/cgi/content/full/84/4/1186

 

[tobagotwo]

Grammatically, I can see what Scott read. It's poorly worded, so inflection and other context would have meant everything. However, it makes the most sense to parse it as: (Life expectancy after aortic valve replacement is shown to be normal after the Ross procedure) (although [it's] less than in an age and sex matched population, if a mechanical valve is used.) I believe he is saying that there is a statistical benefit to the mechanical valve over the Ross Procedure. I believe this is a reasonable, as a percentage of people were given Ross Procedures who shouldn't have been, based on what is now becoming understood about their tissue profiles, and wound up with aortic re-ops on hearts now affected on both the right and left sides.

As far as the Ross Procedure, failures are more frequent with people who have bicuspid valves because they are more likely to also have related connective tissue disorders. Not all do, and not all that do are ever affected by it during their lifetime: but some are.

To my (amateur) point of view, any other/further issues with the root or aorta along with the bicuspidism only heighten the chance that the individual has other connective tissue problems. It increases the likelihood that the harvested pulmonary valve will have or will develop mixomatous tissue over time, and will thus be much less likely to go the distance.

When it goes well, the Ross is a beautiful thing, the gold standard of aortic replacement.

Best wishes,