Ismail El-Hamamsy, MD, Cardiologist at Mt. Sinai Hospital, talks about the Ross procedure and how the operation can improve a person’s quality of life after the surgery.
I wanted to ask you, first of all, about the Ross procedure. We talked to your patient who had heard of TEVAR, that had saw the option of open heart surgery, but had never heard of the Ross procedure before. So, for our viewers who are not familiar, what is it?
EL-HAMAMSY: The Ross procedure is an operation that essentially is aimed at trying to restore patients’ long-term survival and quality of life whenever they have disease of the aortic valve that requires replacement. Unlike the alternatives which you just mentioned, like TEVAR or using a bovine valve or using a mechanical valve, what we do when we do a Ross is that we actually borrow another valve from the patient’s own heart the pulmonary valve, which is a mirror image of a normal aortic valve. By doing so, what we have is a living autologous valve in the aortic position, which is the most important position in the heart. By having that living valve that can adapt to different conditions, that is the patient’s own cells and tissues, what we’ve realized in the last decade or so looking at long-term cohorts of patients is that of all the replacement options, it is the only operation that can actually restore long-term survival of the patients to that of the general population people that don’t have any aortic valve disease. They live just as long up to 20 and even 25 years now after surgery. More importantly, in terms of quality of life and exercise capacity and the need for any medication, it is the one operation that is most compatible with a completely normal lifestyle. There are no restrictions, no medications, no limitations in terms of how much exercise they can do. So for any active adult who requires aortic valve replacement, it is certainly an option that needs to be considered but the main issue with the Ross procedure is the fact that it’s a technically more complex operation than a regular aortic valve replacement. Everything I’ve said hinges on the ability to have it done in a high-volume center with real expertise with this operation.
I was going to ask you, if you could, in layman’s terms, just describe for me how you would go about doing the procedure. You mentioned we borrow the pulmonary valve and in my head I’m like, you going to give it back? Or how does that work.
EL-HAMAMSY: That’s a perfect question. As I said, we borrow the pulmonary valve to put it in the aorta position and then we replace the pulmonary valve with a human cadaveric pulmonary valve. So, it’s a bit like a domino operation, and the idea being that because the aortic valve is the most important valve in the heart, it’s where we want the ideal substitute. If I had to describe the ideal substitute, it would be something that would be a mirror image of an aortic valve, it would be something that is living because the valve does a lot more than just open and close and, ideally, it would be from the patient’s own cells and tissues so that it remains living in the long term. The difference with the pulmonary side is that the pressures are a lot lower on the pulmonary side. So having a substitute that is not the patient’s own and that is not a living one tolerates or performs fine over the long run because the pressures and the stresses are so much lower on it. In other words, if we took a replacement like the one that we put on the pulmonary side and we put it on the aortic side instead, it just simply wouldn’t last very long. That would mirror what we see in terms of results with animal valves with bovine valves that we put in the aortic position, particularly in younger patients.
I’m going to back up a little bit now that I have the background on tape about the surgery. Tell me about aortic valve disease. Raj worked out, ate healthy, he’s like the poster boy for good, clean living, yet here he is with this sudden problem. So what causes it in some patients?
EL-HAMAMSY: Three main categories of things can affect an aortic valve. The most common is just simply getting old. Patients or individuals in their 70s and 80s will have perfectly normal aortic valves, but just the wear and tear of these valves eventually leads to them becoming thicker, to having calcium deposits, and the valve doesn’t open as well as it should. It’s what we call aortic stenosis. Patients in their 70s and 80s are best served either with standard surgery and a bovine valve or with TEVAR procedures, which have really become very popular and with very favorable results in the last decade or so. The second reason why patients may present with aortic valve disease is a congenital malformation in other words, an inborn defect. The most common cardiac malformation is something we call a bicuspid aortic valve. In other words, a normal aortic valve is formed of three little trapdoors that open and close with every heartbeat. Having a bicuspid aortic valve means they only have two of those. That’s the most common cardiac malformation in the population. About one to two percent of the population that is born with it. And the natural history of a bicuspid aortic valve is that it starts to fail when patients turn 40 or 50 or sometimes 60 years old. These patients tend to present for surgery or for intervention at a younger age than their older counterparts with normal valves, and that’s exactly what our patient Rajiv had. He was born with a bicuspid aortic valve, which worked fine for about 50 years and then started showing some calcium deposits, it wasn’t opening quite as well and eventually led to when we looked at the echocardiogram, the valve was really very, very, very narrowed. So time came to do the surgery and that’s a very common scenario that we see. At least for me, being an exclusively aortic surgeon, that is something that I see on a very regular basis it’s younger adults with aortic valve disease.
Who’s the best candidate who makes a good candidate for the Ross procedure? Is it this group of people that are in their 40s and 50s, you know, with a lot of life to go?
EL-HAMAMSY: Yeah. You know, the – and one should focus on the Ross, but really, more broadly, we should focus on reconstructive aortic surgery. So the Ross on the one hand – and in some instances, we’re actually able to repair the valve itself – the aortic valve. And – which also achieves the same benefit or the rationale of doing a Ross, which is that we keep the patient’s own valve in position. And so the valve is a living valve, it’s the patient’s own cells, and so it performs all the functions that a normal aortic valve does. So whether we repair the valve or we do the Ross, both of these types of operations, because of their unique biological features that come with it, translate into, as we said earlier, better long-term outcomes. So who are the patients who will benefit most from this? They will be patients with an anticipated life expectancy of 15 years or more. So in other words, someone who is 60 years old in the general population, when we look at the life expectancy, is anticipated to live another 25 years. So even a 60-year-old stands to benefit from aortic valve repair or a Ross procedure. Again, provided it can be done in a high-volume center with the required expertise. And certainly, the younger we get, the more of a benefit there is of doing a valve repair or a Ross because the alternatives perform even less well as patients get younger. A bovine valve wears out very quickly in patients under the age of 60 or 50, and a mechanical valve would require the patients to be on lifelong blood thinners, you know, for 30 or 40 years, and that comes with a very high risk of having either a major bleeding event or a stroke.
Is there anyone for whom this is really not a good idea, either the repair or the Ross procedure?
EL-HAMAMSY: The repair is not a good idea if the valve is very calcified, so it really depends on the anatomy of the valve itself. Outside of that, any patient is a good candidate for an aortic valve repair. The Ross procedure is a good option in the majority of patients that require replacement, except if the patients are born with what we call connective tissue disorders. These are genetic disorders where patients are born with aneurysms of the aorta things like Marfan syndrome or Ehlers-Danlos syndrome, and these patients do not perform very well in the long term with the Ross because the pulmonary valve and the pulmonary artery tend to also become aneurysmal like they do on the aortic side. Outside of that, the vast majority of patients are candidates for the Ross procedure provided, as we said, they have, you know, good or they don’t have any conditions medical conditions that would preclude them living another 15 or more years.
Is this easier for a patient to recover? Raj was talking about just feeling better when he was finally able to get up and get around. Is there a time difference? Is it easier for them to recuperate or come back and get back on their feet?
EL-HAMAMSY: You know, there’s no doubt that anytime you preserve biology, the body will recover better. What we do see is, while the time spent in the ICU is the same as a regular operation and the time spent in the hospital is also the same, it’s about four to five days, the recovery after that is actually much faster in these patients. It’s partly because they’re younger, but also importantly because of the fact that it’s just immediately very compatible with the body and it adapts to all the different conditions that the patient goes into, whether it’s exercising or trying to recover after surgery. Rajiv’s example is a very representative one of what we see with patients after a Ross procedure or after aortic valve repair.
I want to ask you a few more questions about Raj. Do you remember when you first met him? Can you tell me a little bit about his story and about explaining the procedure to him?
EL-HAMAMSY: It was actually interesting, I got called by the cardiologist who was actually a family friend of his and this was literally just two months ago and Raj had just moved from Atlanta back to New York City. He was feeling OK, but a little more fatigued, perhaps, so he consulted. When they did the echo, they realized that he had this very severe aortic stenosis. I guess, because Raj is so healthy otherwise, symptoms were very subtle but the echo looked pretty ominous. So, he immediately called me and I went to see him on the same day just after his echo. We sat down and I got to know him a little bit and got to understand what his lifestyle is like and what his life goals are and as you saw, he’s a very, very healthy and active and very, health-oriented and aware patient. For him, it was important to have an operation that would allow him to live a completely normal and fulfilling life. We discussed all the different options, like I do with all the patients and we try to individualize the solution to the given patient. In him, there was no doubt that he was an ideal candidate for it because of just how healthy and how active he was and he just jumped on board. Once he makes up his mind, as you saw, he’s very resilient and very committed to trough the surgery. He recovered in a heartbeat and up and running he is, as he Says.
The fact that he just had surgery last month when you look at him now, what goes through your mind?
EL-HAMAMSY: Oh, there’s nothing that makes us happier as surgeons than to see this. I mean, that gives the full meaning to what we do. Obviously, we like the intellectual and technical challenge but at the end of the day, this is a very human experience and it’s a very strong bond that we have with patients who, going back to his story, I met him and within 15 minutes he trusted me with his life, basically and the ability for us, in that four hours that we work on his heart, to restore normal survival, normal exercise capacity, normal quality of life, and to see him thriving and happy and out of danger now like he is, it’s something that is, I mean, it’s hard to describe and you never get used to it.
What is the percentage of people aortic valve disease patients who in America over a period of a year and how many Ross procedures are done in the United States. Do you know?
EL-HAMAMSY: No, it’s hard to tell. You know, statistics are hard to come by. Probably around, I would say, three to 500 Ross procedures a year. One thing I will say, though, is that, in the last five years or so, there’s been a true renaissance for the procedure and aortic valve repair, a lot of which has been driven by the research and the work that we’ve, done and produced and over the last decade or so showing these excellent long-term results with the operation. So, there are many centers that are now, starting Ross programs, many of which I’ve helped proctor and do the first cases. That was a couple of weeks ago, I was in Philadelphia, I was in Chicago, many centers in Canada, and I’ll be going to South America to the west coast. So many groups with, you know, aortic surgeons who are now interested in starting a Ross and an aortic valve program what we call a reconstructive aortic program, so that they can serve these patients best and provide them with tailored solutions to their problems that allow them to have a completely normal life in the long term.
Is there anything I didn’t ask you that you want to make sure that people know?
EL-HAMAMSY: I think the most important thing, if I’m a patient, is to really do my homework, to understand my condition, to ask all the questions, to not be afraid of asking a cardiologist or my surgeon even questions about are there any other options? What are the alternatives? Why yes? Why no? Also do some reading. I think it’s always difficult to go on the internet and try to find good information, what is less so but the information is out there and an informed patient will be, much better served in the long term when they partner with the surgeon in their care versus not doing so. I think patients that own their condition and patients that partner with their surgeon and the whole team in their care, I think, in the long run, usually do a lot better.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Ilana Nikravesh
ilana.nikravesh@mountsinai.org
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
