Melanie Cole, MS (Host): Welcome to Better Edge, a
Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me
today is Dr. Christopher Malaisrie. He's a cardiac surgeon and Associate
Director at the Center for Heart Valve Disease at Northwestern Medicine. He's a
professor of Cardiac Surgery at Northwestern University's Feinberg School of
Medicine, and he's here to highlight the Ross procedures at Northwestern
Medicine for us today.

Melanie Cole, MS: Dr. Malaisrie, it's a pleasure to have
you join us. I'd like you to start by telling us a little bit about yourself
and your role at the Northwestern Medicine Bluhm Cardiovascular Institute.

Christopher Malaisrie, MD: Thanks for having me,
Melanie. My name is Chris Malaisrie. I'm a cardiac surgeon at Northwestern
Memorial Hospital. I am also Professor of Surgery at Northwestern University.
And my role downtown here at Northwestern is to lead the program in aortic
surgery as well as aortic valve surgery. My academic roles are Program Director
for the Residency and Fellowship Program, so I train incoming and to-be
surgeons who are going to become cardiac surgeons in the future.

Melanie Cole, MS: Dr. Malaisrie, can you briefly explain
the Ross procedure? Tell us why it's considered a rare surgery, and I'd like a
little bit of an evolution of this fascinating surgery. This is such an
interesting topic we're discussing here today.

Christopher Malaisrie, MD: Sure. No problem. So, the
Ross procedure is named after a surgeon named Sir Donald Ross from Britain. And
it was devised at a time when there was no good artificial valves for patients
with failing valves. So at that time, we neither had good biologic valves nor
good mechanical valves. So, this procedure was devised because we use a natural
substitute, the patient's own pulmonary valve to replace a diseased aortic
valve. Now after 40 years of evolution, what that means is that during open
heart surgery, we excise the patient's diseased aortic valve, either too tight
or too calcified. And we take the patient's pulmonary valve, which lives right
next to it, and use that as a substitute.

Now, in the place of the pulmonary valve, we take a donor
pulmonary valve from another human, which has been frozen, sterilized,
packaged, and pretty much off the shelf. It's in the freezers, ready to go in
the operating room. So in the nutshell, it's a procedure that is complex. It
does require technical expertise to perform. So, you need a good experience to
become proficient. But the benefit to patients is that it's their own natural
parts. So, we find that patients will have a normal lifetime and normal life
expectancy with the Ross procedure.

Melanie Cole, MS: Well, thank you for explaining that to
us. So, why is it not an option for all patients with diseased aortic valves?
What are the indications? Speak about patient selection because that's a really
important aspect of this for offering the Ross procedure to a patient and some
contraindications that you would consider.

Christopher Malaisrie, MD: Yeah. Aortic valve disease
can afflict young patients as young as 20 years old and can afflict patients
that are older as well, out to 80 or 90-year-old. Now, older patients, they
would benefit with less invasive procedures such as transcatheter aortic valve
implantation. We call that TAVI or TAVR. That's a nice operation because it is
a quick operation, very good safety and pretty good durability. However, young
patients are facing a lifetime of potential valve replacements if they were to
take artificial valves, in particular TAVI. So for younger patients, we think
that the Ross procedure's a great procedure because, again, it's the patient's
own living parts that we're using to replace the aortic valve. And we like to
do the Ross procedure for young patients, meaning patients who look like, who
are less than 50 years old or look like they're less than 50 years old because
it's the younger patients that benefit most from this procedure.

Melanie Cole, MS: Speak about any disadvantages and
advantages to this procedure. As you've seen it evolve over the years and that
you're still using it, even though there's the evolution of TAVR, TAVI, all
those that you were mentioning, tell us a little bit why you would choose this.
I know you said younger patients, but what else would make you look into this
procedure?

Christopher Malaisrie, MD: Yeah. The younger patients
benefit the most from the Ross procedure. We find a restoration of normal life
expectancy after valve repair and the Ross procedure. So, patients will look
like they never had valve disease at all to begin with, and that they'll live
just as long as the normal population of their age. So, I think that's the most
compelling reason that we offer this procedure to our patients. There's other
benefits, of course. I think the Ross procedure is resistant to valve
infection. We call that infective endocarditis. Patients still need to be on
prophylactic antibiotics when they do have minor procedures to prevent
infective endocarditis. But the rate of endocarditis and the severity of
endocarditis is a lot better, meaning it's a lot less than patients who have
artificial valves. And the third thing is that the hemodynamics from the Ross
procedure is like a normal valve, so there is no stenosis at all. So, mean
gradients through the valve are very low in the single digits, like less than
five millimeters of mercury. So, that's great for patients who still want that
to live their life with maximal capacity for function and exercise. Older
patients really don't notice it too much, but definitely younger patients who
like to exercise at full bore will benefit from this.

The downside is that there is a rate of valve failure. However,
all valves, whether that's valve replacement or valve repair, can fail. We
estimate that valve failure after the Ross is somewhere between 1-2% per year.
That's not that bad. So if you follow the patient for another 20 years, that
that's about a 20% risk that the patient would need another operation at 20
years, that's actually not that bad. I think that's better than a biologic
artificial valve. But that is probably the price that you pay for the Ross
procedure.

Melanie Cole, MS: And which valve are you talking about
is most likely to fail? Are we looking at the donor pulmonary valve or the
aortic valve of the patient? If you see them fail down the line, which one is
more likely to do that?

Christopher Malaisrie, MD: It's about half and half. So,
the autograft, which is the patient's own pulmonary valve, can fail from
leakiness. That happens because the autograft can dilate, it can get bigger
over time. We have techniques to minimize that. We reinforce the autograft with
Dacron, that's the stiff, sturdy Dacron graft to keep it from dilating, so we
think that we can minimize this risk. The homograft can fail by either getting
too tight or getting calcified or leaking as well. The great thing about this
is I think in about 10 to 20 years, more options will become available to fix
either a leaky autograft or a failing homograft with a transcatheter procedure,
much like a TAVI procedure. There's already devices on the market that can fix
a leaky pulmonary valve, and I think that'll be a good option for patients.

Melanie Cole, MS: Would you like to give any technical
considerations? You mentioned that the experience of the surgeon really factors
in here. Speak a little bit since you are so experienced with this, tell other
providers what you'd like them to know about anything specific. You've
mentioned patient selection and you spoke just a little bit about the procedure
itself, but expand for us a little bit, Dr. Malaisrie.

Christopher Malaisrie, MD: Sure. So, we think about an
isolated aortic valve replacement. I do that through a mini thoracotomy
approach, otherwise known as minimally invasive cardiac surgery. That operation
will be done in about four to five hours, probably about 100 minutes of pump
time. So, it's a straightforward procedure. It's a quick procedure. You think
of that as the baseline operation.

For the Ross procedure, it's going to take longer. The Ross
procedure, I need to perform through a full sternotomy, so it's definitely not
minimally invasive cardiac surgery. It's incision that looks like a coronary
bypass grafting. Pump time for this is going to be about two and a half hours.
That can be a big deal for older patients. But for younger patients less than
50 years old or good-looking patients, they can tolerate an extended operation
and not really miss a beat, so they would have a recovery that is very similar
to patients who had minimally invasive heart surgery, for instance, which I
tell patients to expect about five days of recovery in the hospital. I think
the recovery for younger patients after either a Ross or minimally invasive
valve surgery could look very, very much the same.

Melanie Cole, MS: Dr. Malaisrie, this is just so interesting
to me as an exercise physiologist. Watching these kinds of advancements evolve
in the field of cardiac medicine is really something to see. Are there any
advancements on the horizon? You mentioned a little bit about valve replacement
in the future. What else do you see happening regarding the Ross procedure and
diseased valves?

Christopher Malaisrie, MD: Yeah. I'm hoping that in the
future that we'd get something like we see in science fiction that we can grow
a brand new valve in a Petri dish in a lab that is made out of the patient's
own cells. That dream hasn't been realized yet, but that is sort of what we
were considered an ideal valve. A valve that is from the patient's own cells.
It doesn't need to be anticoagulated, meaning it doesn't need to be on warfarin
and can be as durable as a valve that you're born with when you're a baby. So
until that time, I think the Ross procedure is a good in-between step because
the patient gets an operation that can have results that are close to ideal.
But we're searching for procedures that will be the best of both worlds, can be
very durable and also very quick and safe for patients. I think those
procedures are on the horizon.

Melanie Cole, MS: Thank you so much, Dr. Malaisrie, for
joining us today. And to refer your patient or for more information, please
visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get
connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern
Medicine podcast for physicians. Please always remember to subscribe, rate and
review this podcast and all the other Northwestern Medicine podcasts. I'm
Melanie Cole.