16744 Aortic Valve Ross Procedure

Overview

The Ross procedure is a kind of open-heart surgery. It is used when the aortic valve is damaged. The aortic valve is the one-way gate that lets oxygen-rich blood flow out of the heart and into the body. When it is narrowed or leaky, the heart has to work much harder. In the Ross procedure, instead of placing a man-made valve or a valve from a donor, the surgeon moves the person's own pulmonary valve into the aortic valve position. The pulmonary valve is the gate between the heart and the lungs. Because it is very similar to the aortic valve, it can do the aortic job well. The surgeon then puts a donated human valve (called a homograft) where the pulmonary valve used to be. The big plus is that your own valve is living tissue — it keeps behaving like a natural valve, and in children it can even grow as the child grows.

The Ross procedure is not common. Most aortic valve replacements use either a mechanical (man-made) valve or a valve made from animal tissue. The Ross procedure is done less often, mainly in specialist heart centres and mainly for younger people. Your heart team will talk through all the options with you.

It is used most often for children, teenagers and young adults whose aortic valve is narrowed or leaking. Many of them were born with an abnormal valve, such as a bicuspid aortic valve (two flaps instead of three). It can also be considered for some adults whose valve problem cannot be repaired and who want to avoid long-term blood-thinning medicine.

Symptoms

Common symptoms

• Feeling short of breath, especially during activity or when lying flat
• Chest pain or tightness, often brought on by exercise
• Feeling dizzy or light-headed
• Fainting or nearly fainting
• Unusual tiredness or low energy
• A pounding, fluttering or racing heartbeat (palpitations)
• Swollen ankles or feet

Symptoms in children

• Poor feeding, or sweating a lot during feeds
• Slow weight gain or slower growth than other children
• Breathing fast, or working hard to breathe
• Tiring quickly during play or sport
• Chest pain or fainting during activity
• A heart murmur heard by a doctor during a check-up

Symptoms in older adults

• Breathlessness doing everyday tasks like climbing stairs
• Chest tightness when active
• Dizziness or unsteadiness, which can lead to falls
• Low energy and poor stamina
• Swelling in the legs and ankles
• Finding it hard to lie flat in bed at night

Causes

Main causes

• Aortic stenosis — the valve is narrowed and cannot open fully, so less blood gets through
• Aortic regurgitation — the valve does not close tightly, so blood leaks backwards
• A valve that formed abnormally before birth, such as a bicuspid aortic valve
• Rheumatic heart disease, which can follow a strep throat infection that was not treated
• Infection of the valve (called endocarditis)
• Wear and calcium build-up on the valve over many years

Risk factors

• Being born with a bicuspid aortic valve (two flaps instead of three)
• A family history of valve problems or congenital heart disease
• A previous bout of rheumatic fever
• Connective tissue conditions such as Marfan syndrome
• Past infection of a heart valve
• Chest radiotherapy in the past

When to see a doctor

See a doctor urgently if:

• Fever that does not settle, especially with chills or feeling generally unwell
• Breathlessness that is new or getting worse
• Chest pain or dizziness during mild activity
• New swelling in the legs or feet

Book a routine appointment if:

• A heart murmur has been heard and you want it checked
• You have a known valve problem and your regular check-up is due
• You notice you are more tired or more breathless than usual
• You have a family history of congenital heart disease and want advice
• You want to talk through treatment options with your heart team

Diagnosis

Doctors start by asking about your symptoms and listening to your heart with a stethoscope. A murmur (the sound of disturbed blood flow) is often the first clue. From there, heart tests show how well the valve is working and how much strain the heart is under. The results help the heart team decide whether surgery is needed and whether the Ross procedure is a suitable option for you.

Tests that may be done

• Echocardiogram — an ultrasound scan of the heart that shows how the valve opens and closes and how strongly the heart pumps
• Electrocardiogram (ECG) — a painless recording of the heart's electrical rhythm
• Chest X-ray — shows the size and shape of the heart
• Cardiac MRI or CT scan — detailed pictures of the valve and blood vessels
• Cardiac catheterisation — a thin tube passed into the heart to measure pressures and check the coronary arteries
• Blood tests — to check general health and look for signs of infection

What to expect at your appointment

Most tests are quick and painless. An echocardiogram is like a standard pregnancy scan and takes about half an hour. You may be asked to avoid eating for a few hours before a scan or catheter test. After the tests, your heart team will explain the findings and talk through the treatment choices, including the benefits and risks of each one.

Treatment

Treatment depends on how damaged the valve is, your symptoms, your age and your overall health. When the valve is badly narrowed or leaking, the valve usually needs to be repaired or replaced. There are several ways to replace an aortic valve: a mechanical (man-made) valve, a valve made from animal tissue, a donated human valve, or the Ross procedure using your own pulmonary valve. Each option has trade-offs, and the best choice is personal to you.

Self-care at home

• Keep taking any medicines your doctor has prescribed and do not stop them on your own
• Keep up with your heart check-ups, even when you feel well
• Look after your teeth and gums, and tell your dentist about your heart valve
• Stay active within what feels comfortable, and ask your team what exercise is safe
• Eat a balanced diet and avoid smoking
• Tell any doctor, nurse or dentist that you have had valve surgery
• Plan ahead if you travel — carry your heart details with you

Medical treatments

For some people, medicines help the heart work better and ease symptoms, but no medicine can fix a badly damaged valve. When the valve itself needs replacing, the heart team will discuss the general types of replacement. A mechanical valve is very hard-wearing but needs lifelong blood-thinning medicine. A tissue valve (made from animal tissue) usually does not need blood thinners but may wear out over time. The Ross procedure uses your own pulmonary valve, so it keeps a living valve in the aortic position and usually avoids long-term blood thinners, but it is a longer operation involving two valves. Your surgeon will explain which approach suits your heart, your age and your life.

When is surgery considered?

Surgery may be recommended when symptoms appear, when the valve is severely narrowed or leaking, when the heart is starting to enlarge or weaken, or when tests show the heart is under significant strain. In children, timing also depends on growth and the size of the valves. Your heart team will weigh the risks of waiting against the risks of operating.

Living with this condition

After the operation, most people go back to normal life, work or school after a period of recovery. You will have a scar down the middle of your chest and will need to take it easy at first — no heavy lifting until your team says it is safe. You will have regular check-ups, usually with an echocardiogram, to keep an eye on both valves. Many people feel much better than they did before surgery, with more energy and less breathlessness.

Lifestyle tips

• Build activity back gradually and follow your team's advice about returning to sport
• Keep your teeth and gums healthy, since mouth bacteria can reach the heart
• Avoid smoking and keep alcohol within sensible limits
• Get plenty of sleep and manage stress where you can
• Tell your doctor if you are planning a pregnancy, or if you become pregnant
• Carry details of your valve surgery with you in case of an emergency

Diet and exercise

A balanced diet with plenty of vegetables, fruit, wholegrains and lean protein helps your heart. Watch out for too much salt if you have swelling or high blood pressure. Regular gentle exercise is good for the heart and mood — walking, swimming and cycling are good starting points. Avoid very heavy lifting or hard competitive training until your heart team gives the go-ahead. Ask them to help you build a plan that fits your life.

Mental health and emotional wellbeing

It is completely normal to feel anxious or low before or after heart surgery. Some people worry about the future, about another operation, or about their scar. Others feel tired and tearful for a while. These feelings usually ease with time, but you do not have to put up with them on your own. Talk to your heart team — they can point you to counselling or a psychologist. If you ever feel you cannot cope, please reach out to your local crisis support line or emergency services straight away.

Prevention

Most valve problems that lead to a Ross procedure cannot be prevented, because they are caused by how the valve formed before birth or by wear over time. There are still some things that help: getting strep throat treated properly, keeping teeth and gums healthy, and having regular check-ups if you have a known valve issue. If you have a family history of congenital heart disease, ask your doctor whether any checks are advised for your family.

Vaccines

Keep up with routine vaccinations, including flu and pneumonia vaccines if your doctor advises them. Vaccination helps you stay well and lowers the risk of infections that could be serious for someone with a heart valve problem. Ask your GP or pharmacist what is recommended for you.

Screening programmes

If you or a close family member has a bicuspid aortic valve or another congenital heart condition, your doctor may suggest heart checks for other family members. Screening usually means a simple examination and an ultrasound scan of the heart.

Complications

If left untreated

• The heart may become enlarged and weaker, leading to heart failure
• Breathlessness, tiredness and swelling may steadily get worse
• The heart rhythm may become irregular
• There is a small but serious risk of sudden fainting or sudden death from a badly narrowed valve
• The valve may become infected more easily

Long-term outlook

Most people who have a Ross procedure do well. Because the valve used for the aortic position is the person's own living tissue, it tends to work well and, in children, it can grow. The donated pulmonary valve may wear out after many years and need replacing in some people, and some people need further surgery at some point. Your heart team will keep watching both valves with regular scans. Many people go back to school, work, sport and family life — and having a plan in place usually makes the future feel more steady, not less.

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