Ross Procedure for aortic stenosis:
Stenotic aortic valve replaced with pulmonary valve
The Ross procedure. The diseased aortic valve and a segment of the aortic artery (X) are removed. A segment of the pulmonary artery containing the pulmonary valve (P) is excised and then placed in the aortic position, replacing the diseased tissue. A cadaveric pulmonary valve (C) is then placed in the pulmonary position
Pulmonary AutograftUsing the patient's own pulmonary valve to replace the aortic valve is known as the Ross procedure, after Sir Donald Ross, the British surgeon who pioneered its use. The pulmonary valve is replaced with a pulmonary homograft, which has a life expectancy of 20-30 years27 (figure 2). The patient's own pulmonary valve in the aortic position has a similar life expectancy, is resistant to infection and does not warrant formal anticoagulation. The drawbacks are primarily related to the technical difficulty of both procedure and reoperation. Many more surgeons have been discouraged by the steep learning curve and abandoned the operation, than those who have managed to successfully adopt it as part of their repertoire.
Operative RiskThe operative mortality associated with aortic valve replacement varies between 2% for an otherwise fit patient in the elective setting, to over 30% for a combined or emergency procedure in a patient with multiple co-morbidity. This is a useful point to introduce a powerful tool used by cardiac surgeons to predict mortality of a given procedure for a particular patient. The EuroSCORE system is one of a number of scoring systems derived from studies of large populations of patients (table 3). With the knowledge of 12 clinical variables such as age, sex, serum creatinine and left ventricular dysfunction, a percentage operative risk can be quoted for that patient, which has been shown to be accurate in all but the highest risk cases where mortality is generally underestimated. The best operative mortality for aortic stenosis according to EuroSCORE would be approximately 3%. UK registry data give the mortality for isolated aortic valve replacement at 2.2% for mechanical valves, 4% for bioprosthetic valves and 5% for homograft replacement.[29] This may reflect the higher proportion of young, low-risk patients undergoing mechanical valve replacement. Surgeon-specific data in the UK suggest that variability between individual surgeons accounts for less than 0.4%.[29] The operative risk of a mechanical valve replacement is similar to that for a tissue valve. The Ross procedure carries an increased risk of up to 7.4%.[30] It is also apparent from EuroSCORE that concomitant coronary artery bypass grafting caries a substantial additional risk.[31]
The risk of stroke (because of emboli from the calcified valve, the aortic cannulation site, hypoperfusion or haemorrhage) is 3% in patients without other risk factors for cerebrovascular events. In addition to the problems with post-operative management described above, patients are warned that aortic valve replacement carries a risk of conduction abnormalities requiring antidysrhythmics, or occasionally permanent pacemaker insertion. The other main peri-operative complications are - as for any open heart surgery - chest infection, pleural effusion, post-operative haemorrhage requiring resternotomy, wound infection which may require further surgery, and acute renal failure.
Aortic Stenosis / Repair 
Aortic Stenosis is a narrowing or obstruction of the aortic valve, causing it to not open properly and to obstruct the flow of blood from the left ventricle to the aorta. The Aortic Valve is thickened and narrowed leading to the development of abnormally high pressure in the left ventricle. The left ventriclular wall becomes thickened ("Hypertrophied"). Stenosis (narrowing) of the aortic valve restricts flow into the Aorta. This leads to the presence of a heart "murmur". Often the narrowing is mild and does not put significant strain on the heart.
Aortic Stenosis
Aortic Stenosis is caused by many disorders. One cause is rheumatic fever. Other causes include calcification of the valve and congenital abnormalities. There may be a history of other valve diseases, coronary artery disease, or a heart murmur. While a normal valve has three parts (leaflets or cusps), a stenotic valve may have only one (unicuspid) or two (bicuspid) thickened and stiff cusps.
Balloon Valvuloplasty - Depending on the severity of the valve stenosis a procedure called balloon valvuloplasty may be used to stretch the aortic valve. During cardiac catheterization, a special catheter containing a balloon is placed across the constricted or narrowed valve. The balloon is inflated and the valve is stretched open. Treatment does not completely cure the problem and the valve sometimes tends to develop further problems with time, sometimes needing re-operation or further balloon stretching.
Sometimes the stenosis is severe and symptoms occur in infancy. Children with aortic stenosis usually have no symptoms but in some, chest pain, unusual tiring, dizziness or fainting may occur. The need for surgery is determined by the degree of severity of the stenosis. In children, the surgeon may be able to enlarge the valve opening. Although the surgery may improve the stenosis, the valve remains deformed. Eventually, replacing the valve may be necessary.
Aortic Valve Replacement
When the aortic valve is very abnormal and if it cannot be effectively repaired a valve replacement operation may be recommended. This may involve the use of an artificial valve, but in many cases the patient's own normal pulmonary valve can be used. This is called the 'Ross Operation' (or Pulmonary Autograft)
Ross Operation
The healthy Pulmonary Valve is removed and sewn into the position of the damaged Aortic Valve. The Pulmonary Valve itself is then replaced with a 'Homograft Valve'. The advantage of this operation is that the new aortic valve will grow with the child and the Homograft Valve, which can be large enough to allow for growth, is not subjected to high pressure and can last much longer in the position of the low pressure Pulmonary Valve - though it is likely that it will eventually need to be replaced at a later date.
Subaortic Stenosis
In this condition the narrowing is below the aortic valve (indicated by arrow). The effect on heart function is similar to aortic valve stenosis. In many cases the obstruction is produced by a 'membrane', but other types of subaortic stenosis also occur - notably a 'muscular' type (also called "Hypertrophic Obstructive Cardiomyopathy" (HOCM) or "Idiopathic Hypertrophic Subaortic Stenosis" (IHSS).
Lifelong medical follow-up is necessary in children with aortic stenosis because even mild stenosis can progress or worsen with age and surgical relief of the obstruction is sometimes incomplete. Following surgery the valve function often remains mildly abnormal. Some patients may have to restrict their participation in certain types of exercise, so check with your pediatric cardiologist about these kinds of exercise limitations.