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Ann Thorac Surg 2004;78:1489-1495
© 2004 The Society of Thoracic Surgeons

Review

The Ross II Procedure: Pulmonary Autograft in the Mitral Position

Thanos Athanasiou, MD, PhDa,*, Ashok Cherian, MDa, Donald Ross, FRCS

a Department of Robotic and Minimally Invasive Cardiothoracic Surgery, St. Mary's Hospital, London, United Kingdom

* Address reprint requests to Dr Athanasiou, Robotic and Minimally Invasive Cardiothoracic Surgery, St. Mary's Hospital, 70 St. Olaf's Rd, Fulham, London SW6 7DN, UK
tathan5253{at}aol.com


   Abstract
Top
 Abstract
Introduction
 Historical Perspectives
 Material and Methods
 Results
 Surgical technique
 Comment
 Conclusions
 Acknowledgments
 References
 
The surgical management of mitral valve disease in women of childbearing age, young patients, and children with congenital mitral valve defects is made difficult by the prospect of lifelong anticoagulation. We suggest the use of a pulmonary autograft in the mitral position (Ross II procedure) as an alternative surgical technique. We present a review of the literature, historical perspectives, indications, selection criteria, and surgical technique for the Ross II procedure. Our literature search identified 14 studies that reported results from the Ross II operation. Performed in 103 patients, the overall in-hospital mortality was 7 (6.7%), with a late mortality of 10 (9%). Although further research is needed, current evidence suggests the Ross II operation is a valuable alternative in low-risk young patients where valve durability and the complication rate from other procedures is unsatisfactory and anticoagulation not ideal.


   Introduction
Top
 Abstract
 Introduction
Historical Perspectives
 Material and Methods
 Results
 Surgical technique
 Comment
 Conclusions
 Acknowledgments
 References
 
Historically two main strategies have been employed for the surgical treatment of mitral valve disease. The first option is to attempt repair of the valve, proceeding to replacement if this fails. Valve repair, which maintains host tissues, was first applied in the preopen heart era [1, 2] and is therefore an older concept than valve replacement. If indeed the valve requires replacement, the only way to avoid anticoagulation is to develop a suitable biologic substitute. The second option is the newly designed "bovine quadrileaflet stentless xenograft," which has the same anticoagulation benefits as a homograft, although long-term outcome results are still pending [3].

Rheumatic heart disease is still the most common worldwide indication for mitral valve replacement, particularly in developing countries. Severe congenital malformation of the mitral valve affecting the subvalvular apparatus or leaflets is another important indication for mitral valve replacement. Patients who undergo stented mitral valve replacements require an organized postoperative anticoagulation program, the cost of which is often unaffordable in many Third World countries. These stented valves have also been associated with early degeneration and calcification, especially in young rheumatic patients [4]. Mitral valve homografts were thought to be the solution, but recent results have raised a question over their durability, especially in young patients [5].

Another approach to mitral valve replacement is the use of an inverted pulmonary autograft in the mitral position (Ross II operation). In 1967 Ross undertook this procedure instead of an aortic homograft. [6]. Encouraging long-term follow-up results of the initial patient series [7] has led to the technique being adopted by Kabbani and colleagues in Syria [8].

We reviewed the worldwide literature that reports on the use of the Ross II procedure. In this paper we present the historical perspectives behind the procedure, short-term and medium-term results, indications, and selection criteria for the operation. By doing this we hope to highlight its advantages and disadvantages.


   Historical Perspectives
Top
 Abstract
 Introduction
 Historical Perspectives
Material and Methods
 Results
 Surgical technique
 Comment
 Conclusions
 Acknowledgments
 References
 
Early development of the Ross II procedure was based on experimental work on dogs and was performed in 1966 in Czechoslovakia by Hubka [9], who mounted unstented (naked) homografts in the left atrium, avoiding any obstruction of the blood flow to the aorta (Fig 1). The bases of the cusps were attached to the left atrial wall, but such tenuous attachments allowed plunging or prolapse of the conduit wall.



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  		Fig 1. Early development of the Ross II procedure by Hubka.

 
Ross undertook intermediate development of the operation, which included initially a "life buoy-type" ring to reinforce the attachment of homograft on the left atrium and later, a loose Dacron (DuPont, Wilmington, DE) conduit to limit lateral expansion of the homograft sinuses lying unattached in the left atrium.

In 1983 Yacoub and colleagues reported the largest available series of implanted aortic homografts in the mitral position by using the largest available sizes (25 to 30 mm in diameter) and fixing them inside a 35-mm Dacron tube with a collar [10]. In this late development of the operation, he covered the collar with autologous pericardium. This modification created a false floor into the atrium that was used to limit lateral distention of the conduit during systole. As a result the term top hat was born (Fig 2). Freedom from valve degeneration was 97% at 5 years and 48% at 10 years [10, 11].



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  		Fig 2. The "top hat" modification to the Ross II procedure.

 
Of late, the operation has fallen into abeyance in favor of porcine bioprostheses and mitral replacement because of the difficulties of preparing the valve at surgery and difficulties of removal at a second operation.


   Material and Methods
Top
 Abstract
 Introduction
 Historical Perspectives
 Material and Methods
Results
 Surgical technique
 Comment
 Conclusions
 Acknowledgments
 References
 
A literature search (MEDLINE) of studies reporting on implantation of pulmonary autografts in the mitral position published between 1965 and 2003 was performed. The following keywords were used: pulmonary autograft and mitral valve," "pulmonary autologous valve and mitral valve replacement," and "Ross II." The articles were also identified by using the function "related articles" in MEDLINE.

We defined the Ross II procedure as the implantation of a pulmonary autograft in the mitral position. We would like to clarify that studies that reported the implantation of aortic or pulmonary homografts in the mitral position were not included in our review. We considered the top hat to be a technical modification of the operation.

The information extracted from each publication that reported on the Ross II operation was: first author, operating period, type of the study, selection criteria, exclusion criteria, number of patients operated on, early mortality, major in-hospital morbidity, and medium-term follow-up. All studies that reported more than 5 cases are tabulated in Table 1. Care was taken to avoid the inclusion of articles that reported on the same patient population.


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  		Table 1. Reported Case-Series on Ross II Operation

 

   Results
Top
 Abstract
 Introduction
 Historical Perspectives
 Material and Methods
 Results
Surgical technique
 Comment
 Conclusions
 Acknowledgments
 References
 
Our literature search identified 14 studies that reported on the application of the Ross II operation in the clinical setting [6–8, 12–22]. Some of the 14 studies involved the same patient group, so 6 case reports [12–17] and 3 case series [7, 18, 22] were used to calculate the total number of cases performed and relevant early and late outcomes. A summary of the three published case series is presented in Table 1.

Early Mortality
The procedure was performed in 103 patients with an overall in-hospital mortality of 7 (6.7%). In the first series performed by Ross, a mortality of 1 out of 8 was reported, with intraoperative bleeding as the primary cause [7]. In the second published series by Kabbani, mortality was reported as 4 out of 80, for varying reasons. The first patient suffered a major cerebrovascular event, the second developed acute respiratory distress syndrome, the third encountered intraoperative bleeding, and the fourth patient went into acute renal failure [22]. Finally, in the third series performed by Kumar, 2 patients died intraoperatively, the first was due to pulmonary edema and cardiac failure, and the second was due to intractable ventricular tachyarrhythmia [18]. It is worth noting that when the results from the three case series are combined, intraoperative bleeding was identified as the cause in three out of seven intraoperative deaths.

Perioperative Morbidity
Extraction of perioperative morbidity data was possible from the same three case series [7, 18, 22]. We identified the following nonfatal procedure-related complications among these 98 patients: perioperative myocardial infraction in 2 patients, low cardiac output in 3 patients (2 of which required an intraaortic balloon pump), perioperative bleeding in 3 patients, reexploration for bleeding or postpericardiotomy syndrome in 2 patients, and atrioventricular dissociation that required pacing in 3 patients. It is characteristic that the incidence for each of these complications is lower than 5%. In the two more recent series [18, 22], the length of stay for most patients was about 1 week.

Follow-up Data
Two recent series report on short-term and medium-term functional status after the Ross II operation. In the first [18], the 8 survivors were in New York Heart Association (NYHA) functional class I, with excellent autograft and homograft function at a follow-up of 2 to 20 months (mean 9 months). In the second report [22], echocardiographic follow-up confirmed excellent function of the pulmonary autograft in the mitral position with freedom of mitral stenosis and mitral regurgitation being 97% and 94%, respectively, at up to 36 months of follow-up (mean 25 months). Sixty-two patients remained in New York Heart Association functional class I-II during the follow-up period.

In the initial Ross series [7], 1 patient died 3.5 years after the operation. Mitral valve replacement for subacute bacterial endocarditis was required in 2 patients and for ruptured pulmonary autograft cusp in 1 patient. No late deaths or pulmonary autograft failure were reported in the series performed by Kumar [18]. In the largest and most recently published series by Kabbani [22], nine late deaths were reported. Of these 3 patients had subacute bacterial endocarditis, 1 had a paravalvular leak requiring reoperation, 1 patient developed delayed tamponade due to excessive anticoagulation, 2 patients died from undetermined causes, and 2 from causes unrelated to the procedure. In the same series, 2 patients developed progressive pulmonary xenograft stenosis during the follow-up period.

The late mortality for the procedure was 9% (10/103). Subacute bacterial endocarditis was identified as the most common cause of mortality or requirement for mitral replacement in the medium-term to long-term follow-up period. It is important to emphasize that long-term follow-up data for the Ross II procedure is fragmented and therefore has not yet been adequately evaluated.


   Surgical technique
Top
 Abstract
 Introduction
 Historical Perspectives
 Material and Methods
 Results
 Surgical technique
Comment
 Conclusions
 Acknowledgments
 References
 
The technique and its modifications (Figs 3 and 4) have previously been described in detail [7, 17, 21]. The recommended operative steps are as follows:

  1. The patient is placed on cardiopulmonary bypass with bicaval cannulation.
  2. An 8-cm x 8-cm pericardial patch is prepared with a 2.5-cm hole in the center (please note this step is only necessary if the surgeon intends to use the top hat configuration).
  3. Either a left atriotomy or a transseptal approach (depending on the size of the left atrium) is used to explore and evaluate the mitral valve.
  4. The pulmonary autograft is removed in a classic fashion [23].
  5. The new mitral valve is prepared with either a collar of pericardium (top hat procedure) or alternatively without. The pulmonary autograft is inserted inside a Dacron conduit (2.5-cm long) by the assistant, while the surgeon reconstructs the right ventricular outflow. The technique for the top hat procedure is undertaken as follows:
    1. The autograft is attached to the Dacron conduit with temporary stay sutures placed both proximally and distally.
    2. The pericardial collar is then passed inside the autograft, and the edge of the pericardium is attached with stay sutures on the Dacron.
    3. The rim of the pericardial orifice is attached to the proximal part of the Dacron with a running suture including the pericardium, valve rim, and Dacron, in that order. Another running suture is used to attach the distal part of the pulmonary autograft on the Dacron.

  6. The mitral valve is excised, making an effort to preserve the attachments of the papillary muscles in the mitral annulus. Insertion of the "new mitral valve" by suturing the distal part of the Dacron onto the mitral annulus and pericardial collar on to the left atrial wall is performed, avoiding the pulmonary vein orifices. If closure of the left atrial appendage and tricuspid valve is required, it can be performed at this stage.



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  		Fig 3. Autograft in the mitral position without pericardial collar (Kabbani modification).

 


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  		Fig 4. Ross II procedure (autograft in the mitral position with pericardial collar "top hat").

 
Modifications of this technique have been described by Kabbani (removal of the pericardial collar and use of a more rigid version of Dacron) [19, 22] and by Kumar (use of scalloped stent of felt for external support of the autograft) [ 17]. The results from the Kabbani modification have been encouraging, with no reported adverse events or mortality in the last 23 patients of the series. The features of this modification that may improve outcome are a reduced operative time and a lower risk of pericardial collar rupture, both of which make potential reoperation easier. An added advantage is that the creation of a dead space between the pericardial collar and atrial wall is avoided, thereby reducing the risk of both thrombus formation and kinking of the Dacron tube, such as in the case of a paravalvular leak.

The drawback of this modification is that it leaves the conduit uncovered in the left atrium, increasing the risk of thromboembolism because of exposure of blood in the left atrium to foreign material. This is particularly relevant in patients with atrial fibrillation, who are already prone to thromboembolic disease. In these patients a concomitant ablative procedure should be undertaken to complete the long-term benefits of the operation. In Kumar's modification, the stent from the thick Teflon (DuPont, Wilmington, DE) felt does not come in contact with the blood stream, and therefore this does not carry the previously mentioned thromboembolic risk. The shape and size of the Teflon felt can be fashioned on the table according to the autograft itself. The autograft sinuses are intact, and they are free to billow during valve closure.

In patients with congenital stenosis, the Dacron tube does not allow the annulus of the mitral valve to grow with the child. To counter this, Kabbani has described leaving the Dacron tube slit open along one or both sides. At this stage it is important to appreciate the tube and autograft do not need to be the same size (a 25-mm autograft can be inserted in a 28-mm Dacron tube). A "loose fit" will allow the new mitral substitute to function in a more physiologic way, with the autograft sinuses allowed to expand during systole. The impact of these technical modifications on the long-term outcome have yet to be addressed in the literature.

Our review identified three complications that could be directly attributed to the surgical technique. The first was autograft stenosis resulting from kinking of the Dacron tube in 5 consecutive patients early on in the relevant series [20, 22]. This was caused by the use a softer variety of Dacron as well as inadequate removal of the posterior subvalvular apparatus. The second was rupture of the pericardial collar that required reoperation in 2 patients in the early series of Kabbani [22]. The third was a disruption of the proximal suture line in one of the series by Kumar and colleagues [18].

An important finding is that all of these technical failures occurred early on in the relevant published series and had a significant impact in mortality. It therefore highlights the learning curve associated with this operation, which can be applied to each of the steps that comprise this procedure, namely, removal of the pulmonary autograft, construction of the new mitral valve, and the implantation technique.

Transesophageal echocardiography (TOE) should be undertaken preoperatively and intraoperatively to measure the size of the pulmonary autograft and the left atrium, evaluate the valve function, and to identify any clots in the left atrium. The important role of intraoperative TOE for the Ross II procedure has been highlighted in the biggest published study report on the procedure [22]. TOE was used in this study to identify graft stenosis in 5 patients and flail pericardial collar in 2 patients, all of whom required surgical re-intervention.


   Comment
Top
 Abstract
 Introduction
 Historical Perspectives
 Material and Methods
 Results
 Surgical technique
 Comment
Conclusions
 Acknowledgments
 References
 
Our aim in this review article was to analyze previously published literature regarding the use of the Ross II operation. The outcomes we were interested in included early mortality, major in-hospital morbidity, and medium-term follow-up. The limited number of published reports on the Ross II procedure makes it difficult to determine its efficacy. Despite this, we believe that surgeons should be aware of the technique and its advantages in current cardiac surgical practice. The procedure is associated with a learning curve, and others who have experience of it can introduce surgeons who are not familiar with the use of autografts to it.

Ever since the beginnings of mitral surgery, severe pulmonary hypertension and poor left ventricular function have been important risk factors for adverse outcome following mitral valve replacement [24, 25]. This risk is even higher when the right ventricular outflow tract also requires reconstruction during the procedure. For these reasons patients on whom the Ross II procedure is performed must be carefully selected, and those with significant aortic disease, endocarditis, severe pulmonary hypertension (> 80 mm Hg), severe mitral calcification, and severe left ventricular dysfunction should be excluded. Also previous cardiac surgery and pericarditis identified during the operation make harvesting the pulmonary autograft very difficult, and these patients should not be considered for the procedure.

Indications for the Ross II operation include women of childbearing age with mitral valve disease not suitable for mitral valve repair, young patients with contraindication to coagulation, and patients with unrepairable rheumatic mitral valves, especially in developing countries where anticoagulation is not preferable because of its cost and social implications. The operation can also be considered in pediatric patients with congenital mitral valve disease, who otherwise face life-long anticoagulation, and pregnant women who require mitral valve replacement.

Many attempts have been made to identify an ideal mitral valve substitute by seeking to take advantage of the features of autologous (fascia lata) or homologous tissue (human mitral homografts, aortic homografts, pulmonary homografts). A few surgeons have used fascia lata to reconstruct a thee-leaflet valve on a rigid frame, but the failure rate during the first 14 months after implantation has been significant. The use of mitral homografts to replace the mitral valve were successfully reintroduced by Acar and others [26–28], but notably, this has been abandoned even by its promoters because of reports of inferior durability compared with other tissue valves [5].

The encouraging performance of the aortic homograft in the aortic position and the fact that upside down aortic valves can be used for mitral valve replacement motivated surgeons to start using inverted stented aortic and pulmonary homografts to replace the mitral valve [29, 30]. It has become evident that homografts (especially pulmonary) in the mitral position deteriorate earlier than when in the aortic position. Also, mounting of the homografts in a rigid stent or ring is associated with inferior durability [31]. The explanations for homograft failure include physiologic factors responsible for the vulnerability of the homograft under the high left ventricular closing pressure, factors related to the preservation technique, the additional negative feature of the rigid stent or mounting ring, and finally, the obstruction and systolic turbulence in the left ventricular outflow tract caused by the struts.

Young patients and pregnant women comprise a patient group in whom the results of mitral valve replacement with stented valves are not satisfactory [4, 32]. An adverse outcome after mitral valve replacement is also common in the young child. It has been reported that mitral valve homograft implantation is a safe and reproducible technique, but it does not provide durable results and should not be used in young patients. Similarly, other studies have identified young age as a risk factor for an early homograft structural deterioration (degeneration). Cumulative rates for freedom from reoperation for any cause in different age groups suggest careful selection and indications in homograft implantation in the younger patients [33]. Other reports emphasize the use of autografts in pregnancy [34, 35]. In pregnant patients, structural changes have been found at 5 years after placement of the mitral valve bioprosthesis. This may be attributed to the natural course of the bioprosthesis and thus may be independent of any direct effects of pregnancy [32].

More recently, implantation of bovine quadrileaflet stentless xenograft valves in the mitral position has been reported as another option. The implantation technique for this bovine quadrileaflet stentless xenograft mitral valve is more demanding, but the prosthesis is a promising alternative to conventional biologic mitral valve replacement. Midterm results after stentless mitral valve implantation are promising. Preservation of the annuloventricular continuity leads to stable left ventricular function and when combined with ablation therapy, to physiologic hemodynamics. Long-term durability however, remains unproven [36, 37].

Avoidance of long-term anticoagulation with the Ross II procedure has benefits for pregnant women, young patients, and patients in developing countries [38–40]. Data have shown that anticoagulation with low-molecular-weight heparin alone is neither safe nor effective in preventing thromboembolic events after mechanical heart valve replacement. Thromboembolic prophylaxis of pregnant women with mechanical heart valves is best achieved with oral anticoagulation, although this carries an increased the risk of fetal embryopathy. Substituting oral anticoagulation with heparin between 6 and 12 weeks of gestation reduces the fetopathic effects but increases the risk of thromboembolic complications. Low-dose heparin use is definitely inadequate, and the use of adjusted-dose heparin warrants aggressive monitoring and appropriate dose adjustment [39, 40]. Large prospective trials to determine the best regimen for these women are not available.

The management of young patients with valvular heart disease is a difficult problem in developing countries [41, 42], almost all of these being of rheumatic etiology. In developing countries these patients are young, geographically dispersed, and socioeconomically deprived. Hospital attendance is erratic, and compliance with conventional anticoagulation is difficult. The function of mechanical heart valves is critically dependent upon adequate anticoagulation. Fixed-dose warfarin is associated with an increase in thromboembolic events, but no significant increase in mortality or hemorrhagic events, and thus may be an acceptable option where conventional anticoagulation is impracticable. The difficulty of adequate anticoagulation in a population where compliance is erratic and often nonexistent has previously been identified [43].

Mitral valve replacement with the Ross II procedure has advantages over other surgical options. It should be noted, however, that the structure of the replaced mitral valve cannot be compared with a normal mitral valve or a mitral homograft. The main advantages of the procedure are that the new valve is composed of living tissue, is competent, and anticoagulation with warfarin is required for only 3 months. The valve and its mountings are fully flexible, creating a physiologic structure that does not interfere with valve function. The valve lies only in the left atrium and for this reason does not impede the ejection of the left ventricle. Other advantages are that partial or total preservation of the mitral valve apparatus is possible and the procedure is suitable for young candidates.

The main disadvantage of the procedure is that its application requires the sacrifice of the right ventricular outflow. The operation is more technically difficult than standard mitral valve replacements, and there is concern about failure of two valves rather than one in the long-term. We should bear in mind that although the overall in-hospital mortality and morbidity were not increased with the Ross II procedure, fatal complications did occur and were closely related to the learning curve. Myocardial injury-related complications can occur as a result of the excision of the autograft (septal artery injury) and conduction disturbances or obstruction of pulmonary veins because of the suturing of the collar into the left atrium. Technically difficult reoperation and prolonged cardiopulmonary bypass time should both also be considered as disadvantages of the Ross II procedure.

Future development of the procedure
The Ross II is not a static procedure. Although the Ross I operation provided excellent results in all age groups, the complication of right ventricular outflow tract stenosis has not been seen in patients older than 50 years undergoing this procedure. This implies that it offers superior results for aortic valve disease in middle aged and older patients [44]. It follows, therefore, that the Ross II procedure may benefit the elderly patient in whom anticoagulation is associated with significant adverse events. Ablation procedures for chronic atrial fibrillation can be combined with the Ross II procedure to remove the need for anticoagulation in patients with mitral valve disease. Also, any long-term outcomes after the reconstruction of the right ventricular outflow tract can be improved with the use of CryoValve SynerGraft valves (CryoLife Inc, Kennesaw, GA) [45].


   Conclusions
Top
 Abstract
 Introduction
 Historical Perspectives
 Material and Methods
 Results
 Surgical technique
 Comment
 Conclusions
Acknowledgments
 References
 
The Ross II procedure has a long history, but until now has not been widely used by surgeons in the United States and Europe. Interest in the operation has recently been revived by surgeons who are working in countries where rheumatic valvular disease is relatively common, financial resources are limited, and anticoagulation programs are impractical and complicated.

The efficacy of the procedure has not yet been proven, and further evaluation of long-term follow-up is required. From the evidence available thus far, it seems that the procedure is a valuable alternative in low-risk young patients where the durability and complication rate of other available options (mitral homografts, mechanical and bioprosthetic valves) are still not satisfactory.


   Acknowledgments
Top
 Abstract
 Introduction
 Historical Perspectives
 Material and Methods
 Results
 Surgical technique
 Comment
 Conclusions
 Acknowledgments
References
 
The authors would like to thank Mr Omer Aziz for his contribution to the editing of this paper.


   References
Top
 Abstract
 Introduction
 Historical Perspectives
 Material and Methods
 Results
 Surgical technique
 Comment
 Conclusions
 Acknowledgments
 References
 

  1. Bailey CP, O'Neil THE, Glover RP, Jamison WI, Redondo-Ramirez HP. Surgical repair of mitral insufficiency: a preliminary report. Dis Chest. 1951;19:125[Medline]
  2. Harken DE, Black H, Ellis LB, Dexter L. The surgical correction of mitral insufficiency. J Thorac Surg. 1954;28:604
  3. Aybek T, Simon A, Dogan S, Greinecker GW, Moritz A. Two years' clinical experience with a quadrileaflet stentless bioprosthesis in the mitral position. J Heart Valve Dis. 2000;9(5):667–673[Medline]
  4. Eble BK, Fiser WP, Simpson P, Dugan J, Drummond-Webb JJ, Yetman AT. Mitral valve replacement in children: predictors of long-term outcome. Ann Thorac Surg. 2003;76(3):853–859[Abstract/Free Full Text]
  5. Chauvaud S, Waldmann T, d'Attellis N, et al. Homograft replacement of the mitral valve in young recipients: mid-term results. Eur J Cardiothorac Surg. 2003;23(4):560–566[Abstract/Free Full Text]
  6. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. 1967;2(7523):956–958[Medline]
  7. Ross DN, Kabbani S. Mitral valve replacement with a pulmonary autograft: the mitral top hat. J Heart Valve Dis. 1997;6(5):542–545[Medline]
  8. Kabbani SS, Ross DN, Jamil H, et al. Mitral valve replacement with a pulmonary autograft: initial experience. J Heart Valve Dis. 1999;8(4):359–366[Medline]
  9. Hubka M, Siska K, Holec V. Replacement of the mitral valve with an aortic valve homograft implanted into the left atrium. J Thorac Cardiovasc Surg. 1967;53:260–267[Medline]
  10. Yacoub MH, Kittle CF. A new technique for replacement of the mitral valve by a semilunar valve homograft. J Thorac Cardiovasc Surg. 1969;58(6):859–869[Medline]
  11. Qureshi SA, Halim MA, Campalani G, Coe YJ, Towers MK, Yacoub MH. Late results of mitral valve replacement using unstented antibiotic sterilised aortic homografts. Br Heart J. 1983;50(6):564–569[Abstract/Free Full Text]
  12. Serraf A, Bruniaux J, Planche C. [Ross mitral procedure for massive congenital mitral insufficiency]. Arch Mal Coeur Vaiss. 2001;94(5):509–512[Medline]
  13. Yamagishi M, Shuntoh K, Matsushita T, et al. Mitral valve replacement by a Gore-Tex reinforced pulmonary autograft in a child. J Thorac Cardiovasc Surg. 2003;126(4):1218–1219[Free Full Text]
  14. Al Halees Z, Awad MM, Pieters F, Shahid MS, Al Amri MA. Six-year follow-up of a pulmonary autograft in the mitral position: the Ross II procedure. J Thorac Cardiovasc Surg. 1999;117(3):614–616[Free Full Text]
  15. Mitchell MB, Maharajh GS, Bielefeld MR, DeGroff CG, Clarke DR. Emergency pulmonary autograft mitral valve replacement in a child. Ann Thorac Surg. 2001;72(1):251–253[Abstract/Free Full Text]
  16. Ishihara K, Nakae S, Fukuchi S, Sawatari K, Yamagishi M, Imai Y. [A case of mitral valve replacement with autologous pulmonic valve in congenital mitral stenosis]. Nippon Kyobu Geka Gakkai Zasshi. 1989;37(7):1381–1385[Medline]
  17. Kumar AS, Aggarwal S, Choudhary SK. Mitral valve replacement with the pulmonary autograft: the Ross II procedure. J Thorac Cardiovasc Surg. 2001;122(2):378–379[Free Full Text]
  18. Roy S, Mohanty A, Kumar AS. Pulmonary autograft mitral valve replacement: initial experience with the Ross II procedure. Indian Heart J. 2002;54(3):276–278[Medline]
  19. Kabbani SS, Jamil H, Hammoud A, et al. Use of the pulmonary autograft for mitral replacement: short- and medium-term experience. Eur J Cardiothorac Surg. 2001;20(2):251–257
  20. Kabbani SS, Jamil H, Hammoud A, Nabhani F, Hariri R, Sabbagh N. The mitral pulmonary autograft: a follow up cautionary report. J Heart Valve Dis. 2000;9(6):801–804[Medline]
  21. Kabbani SS, Jamil H, Hammoud A. Technique for replacing the mitral valve with a pulmonary autograft: the Ross-Kabbani operation. Ann Thorac Surg. 2001;72(3):947–950[Abstract/Free Full Text]
  22. Kabbani SS, Jamil H, Hammoud A, et al. The mitral-pulmonary autograft-assessment at midterm. Ann Thorac Surg 2004 (in press)
  23. Ross DN. Replacement of the aortic valve with a pulmonary autograft: the "switch" operation. Ann Thorac Surg. 1991;52:1346–1350[Abstract]
  24. Vincens JJ, Temizer D, Post JR, Edmunds LH Jr, Herrmann HC. Long-term outcome of cardiac surgery in patients with mitral stenosis, and severe pulmonary hypertension. Circulation. 1995;192(9 Suppl II):137–142
  25. Kirklin JW, Barratt-Boyes BG. Mitral valve disease with or without tricuspid valve disease. Kirklin JW, Barratt-Boyes BG. Cardiac Surgery. 2nd edition. New York: Churchill Livingstone; 1993. p. 425–489
  26. Acar C, Tolan M, Berrebi A, et al. Homograft replacement of the mitral valve. Graft selection, technique of implantation, and results in forty-three patients. J Thorac Cardiovasc Surg. 1996;111(2):367–378[Abstract/Free Full Text]
  27. Acar C, Gaer J, Chauvaud S, Carpentier A. Technique of homograft replacement of the mitral valve. J Heart Valve Dis. 1995;4(1):31–34[Medline]
  28. Doty DB, Doty JR, Flores JH, Millar RC. Cardiac valve replacement with mitral homograft. Semin Thorac Cardiovasc Surg. 2001;13(4 Suppl 1):35–42[Medline]
  29. Somerville J, Ross D, Ross JK. Mitral valve replacement with stored inverted pulmonary homograft valve. Thorax. 1972;27(5):583–585[Abstract/Free Full Text]
  30. Oh W, Somerville J, Ross DN, Ross KJ, Emanuel R. Mitral valve replacement with preserved cadaveric aortic homografts. J Thorac Cardiovasc Surg. 1973;65(5):712–721[Medline]
  31. Angel WW, Pupello DF, Bessona LN, et al. Effect of stent mounting on tissue valves for aortic valve replacement. J Card Surg. 1991;6:595–599[Medline]
  32. Avila WS, Rossi EG, Grinberg M, Ramires JA. Influence of pregnancy after bioprosthetic valve replacement in young women: a prospective five-year study. J Heart Valve Dis. 2002;11(6):864–869[Medline]
  33. Sadowski J, Kapelak B, Bartus K, et al. Reoperation after fresh homograft replacement: 23 years' experience with 655 patients. Eur J Cardiothorac Surg. 2003;23(6):996–1000[Abstract/Free Full Text]
  34. Dore A, Somerville J. Pregnancy in patients with pulmonary autograft valve replacement. Eur Heart J. 1997;18(10):1659–1662[Abstract/Free Full Text]
  35. Kabbani SS. Is an optimal mitral substitute within reach? Ann Thorac Surg. 2000;69(6):1651–1652[Free Full Text]
  36. Walther T, Lehmann S, Falk V, Walther C, Doll N, Rastan A, et al. Midterm results after stentless mitral valve replacement. Circulation. 2003;108(Suppl 1):II85–89
  37. Hofmann B, Cichon R, Knaut M, et al. Early experience with a quadrileaflet stentless mitral valve. Ann Thorac Surg. 2001;71(5 Suppl):S323–326[Abstract/Free Full Text]
  38. Balasundaram S, Kumar N, Gometza B, Duran CM. The problems of valve surgery in a developing country. J Cardiovasc Surg (Torino). 1991;32(5):564–569[Medline]
  39. Leyh RT, Fischer S, Ruhparwar A, Haverich A. Anticoagulant therapy in pregnant women with mechanical heart valves. Arch Gynecol Obstet. 2003;268(1):1–4[Medline]
  40. Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med. 2000;160(2):191–196[Abstract/Free Full Text]
  41. Steer AC, Carapetis JR, Nolan TM, Shann F. Systematic review of rheumatic heart disease prevalence in children in developing countries: the role of environmental factors. J Paediatr Child Health. 2002;38(3):229–234[Medline]
  42. Olivier C. Rheumatic fever–is it still a problem? J Antimicrob Chemother. 2000;45(Suppl):13–21[Abstract]
  43. Buchanan-Leel B, Levetan BN, Lombard CJ, Commerford PJ. Fixed-dose versus adjusted-dose warfarin in patients with prosthetic heart valves in a peri-urban impoverished population. J Heart Valve Dis. 2002;11(4):583–592[Medline]
  44. Bohm JO, Botha CA, Hemmer W, et al. Older patients fare better with the Ross operation. Ann Thorac Surg. 2003;75(3):796–801[Abstract/Free Full Text]
  45. Oury JH, Wojewski P, Doty DB, Oswalt D, Elkins RC. The Ross procedure: overview and midterm results (including early performance and results of the Synergraft valve). Rocky Mountain Valve Symposium XIII, Missoula-Montana, 2003



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