Advancing Aortic Valve Replacement with the Ross Procedure

Pepin Heart Institute at AdventHealth Tampa offers the Ross procedure, a surgical aortic valve replacement (AVR) technique that uses a patient’s own pulmonary valve to replace their damaged aortic valve.

Also known as a pulmonary autograft procedure, the Ross procedure is a type of aortic valve replacement, most commonly indicated for people with aortic stenosis or early-onset aortic regurgitation.

Chief of Cardiothoracic Surgery Erol Belli, MD, leads the Ross procedure program at AdventHealth Tampa.

“This procedure gives patients another option,” he says. “It especially gives young patients with valvular heart disease the opportunity to not need lifelong anticoagulation.”

The Origins of the Ross Procedure

Developed in the late 1960s by British cardiothoracic surgeon Donald Ross, MD, the Ross procedure uses a patient’s own healthy pulmonary valve, or pulmonary autograft, to replace their non-functioning aortic valve. A surgeon then replaces the patient’s pulmonary valve with a donated, human pulmonary valve, or pulmonary homograft.

Dr. Ross decided to use a patient’s own pulmonary valve in the procedure because he recognized that it’s a mirror image of the aortic valve and can adapt to the higher blood pressure in the aortic position. He also noted that the pulmonary valve is a living structure that the body immediately accepts.

Currently, the Ross procedure is the only AVR operation that restores patients' life expectancy with aortic valve disease. That’s because it uses the body’s own pulmonary valve, which provides excellent blood flow both at rest and during exercise.

AVR options that use bioprosthetic or mechanical valves significantly reduce the life expectancy of patients, particularly those aged 60 years and younger.

Renewed Interest Driven by Long-Term Outcomes

Still, due to its complexity, the Ross procedure was sidelined for several decades in favor of more reproducible valve replacements, like bioprosthetic and mechanical valves, Dr. Belli explains.

In the 1990s, the technique experienced a resurgence when high-volume centers began publishing long-term outcomes demonstrating improved survival and eliminated anticoagulation burden in Ross patients — particularly those under age 60 — when compared with mechanical and bioprosthetic valves.

“When the long-term data started to emerge, it prompted surgeons to re-examine the procedure,” Dr. Belli says. “That’s when the conversation really shifted.”

Key Advantages of the Ross Procedure

In general, patients who have the Ross procedure experience more “natural” heart function and lower complication risks.

Other major advantages of the technique include:

• Avoidance of lifelong anticoagulation medication
• Excellent blood flow across the valve, both at rest and during exercise
• Improved long-term survival
• Normal quality of life

In addition, the Ross procedure has a very low risk of valve deterioration or infection. In fact, according to a 2024 study published in the American Heart Association’s Circulation journal that examined the 10-year clinical and echocardiographic outcomes following the Ross procedure:

• Only 1.5% of patients required reintervention on their aortic valve
• The total reintervention rate for both the aortic and pulmonary valves combined was 5%

Patients Who are Potential Candidates for Ross

The Ross procedure is typically recommended for patients under age 50, but it’s also often considered for older patients who are expected to live for another 15-plus years, have an active lifestyle and don’t have a chronic health condition.

Other qualifying factors include:

• An ability to tolerate surgical valve replacement surgery
• An inability to take blood-thinning medications (or a desire to stop taking them)
• Future pregnancy plans

“I usually tell patients they’ll be in the hospital for five to seven days and explain that full recovery takes roughly two to four weeks. I also stress it’s a small price to pay not to have to take Coumadin® long term,” Dr. Belli says.

In addition to having a chronic condition like kidney disease, patients do not qualify if they have pulmonary valve disease, a connective tissue disorder or multi-vessel coronary artery disease.

Refer Patients to AdventHealth Pepin Heart Institute for Advanced Aortic Valve Options

For patients who qualify, the Ross procedure has proven, long-term durability as an AVR option when performed by knowledgeable surgeons in a high-volume center. At AdventHealth Pepin Heart Institute, the cardiothoracic team includes surgeons with a decade or more of experience performing the complex surgical technique. The surgeons are also supported by a comprehensive program that offers additional treatments for valve disease, including minimally invasive and complex options.

AdventHealth Pepin Heart Institute’s cardiothoracic surgery program matches each patient with the most appropriate intervention based on factors such as their age, overall health and long-term goals.

If you have a patient with aortic stenosis or regurgitation who may benefit from advanced surgical evaluation, our team is available to consult, review imaging and coordinate care seamlessly.

To discuss a case or initiate a referral, call us at Call813-910-0027

About Dr. Belli

Erol Belli, MD, is a board-certified cardiothoracic surgeon at AdventHealth Tampa’s Pepin Heart Institute. He serves as the chief of cardiothoracic surgery and cares for patients ages 18 and older. Dr. Belli is a helper at heart, drawn to cardiac surgery because it allows him to combine his passion for helping others with his fascination for the intricacies of the heart.