The Ross Procedure for Pediatric Aortic Valve Disease

Your child may need a Ross procedure for severe aortic valve disease, such as aortic stenosis, that can’t be repaired

The aortic valve helps keep blood flowing through the heart in the right direction. When properly formed, the valve has three leaflets (flaps) that open and close with each heartbeat. In babies born with aortic valve disease, their valve may have only one or two leaflets, or the leaflets might be thick and stiff.

In the Ross procedure, surgeons replace the aortic valve with the child’s own pulmonary valve. They use a human donor valve to replace the pulmonary valve.

The Ross procedure has several advantages compared to other heart valve replacement or repair techniques:

• A living valve that grows: The new aortic valve is your child’s own tissue, so it will grow with your child. Artificial (mechanical) valves, valves from other people and animal tissue (bioprosthetic) valves cannot grow and will need to be replaced as your child grows.
• No need for blood thinners: Mechanical valves carry a risk of blood clots, so a child must take blood thinners (anticoagulants) for the rest of their life. Your child’s own valve and tissue valves don’t increase the risk of blood clots.
• Resistance to infection: Your child’s own valve and human tissue valves are less likely to develop infection than artificial and animal tissue valves.
• Efficient blood flow: In the aortic valve position, the pulmonary valve provides the best fit and performance for smooth, steady blood flow. Other replacement valves and repaired valves don’t fit or work as well.
• Long-lasting solution: The new aortic valve may last for your child’s lifetime because it’s your child’s own tissue. However, the replacement pulmonary valve will need to be replaced.

The Ross procedure is a long and technically demanding surgery. Risk factors vary, depending on your child's size and other health problems. Your care team will discuss your child's specific risks with you. Possible risks related to the Ross procedure include:

• Infection
• Excess bleeding
• Irregular heart rhythms (arrhythmias) such as heart block
• Blood clots, which can lead to a heart attack or stroke
• Rare complications from anesthesia, such as allergic reactions to medications

If your child needs a Ross procedure, you’ll likely have many questions. Your child’s care team can provide answers, and here’s what you can expect with the Ross procedure.

What to expect before the Pediatric Ross Procedure?

The day before the surgery, you’ll bring your child to a preoperative visit. The care team will review:

• What time to arrive for surgery
• When your child should stop eating and drinking
• Which medications your child can continue to take and which to stop

Your child may need some tests, which may include:

• Blood tests
• Chest X-ray to view structures in and around the heart
• Echocardiogram to examine the heart and blood flow through it
• Electrocardiogram to evaluate heart rhythm

What to expect during the Pediatric Ross Procedure?

The Ross procedure takes several hours, so be prepared to spend most of the day at our Heart Center.

You and your child will come in the morning to check in and prepare for the surgery. You then meet with the anesthesiologist, the doctor who oversees anesthesia during your child’s procedure. Then you and your child will meet the surgeon and other members of the surgical team, including advanced practice providers and nurses.

The steps of the Ross procedure:

• The surgeon makes an incision down the center of your child's chest and separates the breastbone to access the heart.
• We connect your child to a heart-lung machine, which circulates oxygen-rich blood through your child’s body during the surgery.
• The surgeon removes the diseased aortic valve and the pulmonary valve.
• The surgeon sews the pulmonary valve where the aortic valve had been and the donor valve where the pulmonary valve had been.
• When the valve replacements are complete and your child's heart is beating as it should, we remove the heart-lung machine.
• The surgeon closes your child’s breastbone, muscle and skin and places a dressing over the incision.

What to expect after the Pediatric Ross Procedure?

After the surgery, we take your child to the cardiac intensive care unit (CICU) to begin recovery. Our specialized CICU nurses closely monitor your child as they wake up, checking their vital signs, such as their heart rate, breathing and blood pressure.

For a Ross procedure, the typical hospital stay is 1-2 days in the CICU followed by 3-5 days in a regular inpatient unit.

The care team helps you prepare for your child to come home with instructions for:

• Healthy food and liquids for your child as they recover
• Medications, including dosage, frequency and side effects to watch for
• Exercise limitations, such as avoiding strenuous activities and those that could involve blows to the chest
• Wound care for the incision, including signs to watch for
• Symptoms to call the care team about, such as a fever, increased wound draining or any severe symptoms

After your child goes home:

• Your child may feel tired for several days after surgery.
• Full recovery can take 4-6 weeks, perhaps less for younger children, before they get back to their usual activities.
• Make sure to bring your child in for their follow-up appointments.

Your child needs lifelong care with a cardiologist to monitor their heart health and check for possible complications from the procedure. Your child may also need to take antibiotics before certain medical or dental procedures to prevent an infection of the heart valves.

Thinking about being in the hospital and having surgery can be overwhelming at any age. To help your child get ready for their procedure you can:

• Explain what will happen in clear, straightforward language
• Ask your child questions and encourage conversations
• Reassure your child that the surgery and hospital stay are temporary
• Be patient and affirm your child’s feelings

Child Life Services

Our child life specialists provide personalized support to help your child and family prepare for hospital stays and procedures. Find out more about the therapies, education and activities our child life team provides. If you would like to speak with a child life specialist, please call us at 214-456-6280.

At Children’s Health, our heart surgeons, cardiologists and their teams are here to answer all your questions about aortic valve disease and the Ross procedure. Some questions you may want to ask include:

• What other treatment options do you offer for aortic valve disease?
• How do you decide whether the Ross procedure or another treatment is right for my child?
• What kind of anesthesia will my child receive for surgery? What are the risks?
• Can I be with my child before surgery while they’re being prepped?
• How soon will I be able to see my child after the Ross procedure?
• What is your approach to pain management?