The Ross procedure, also known as the switch procedure, is a cardiac surgery in which a diseased aortic valve is replaced with the patient's own pulmonary valve, followed by replacement of the pulmonary valve with a pulmonary allograft. The Ross procedure was first developed in the late 1960s and has been performed many times since. It remains to be the only operation that allows for aortic valve replacement with a living valve substitute.  Over the years, the original procedure has been gradually modified to perfect the surgical outcome, but the main principles outlining the procedure remain. This chapter will discuss in detail the anatomy of the aortic valve, indications, contraindications, equipment, personnel, preparation, technique, complications, and clinical significance of the Ross procedure.
Four chambers comprise the heart. The superior two chambers are the right and left atria while the bottom two chambers are named the right and left ventricles. Atrioventricular valves separate the atria and ventricles. There are two semilunar valves: the pulmonic valve separates the right ventricle and the pulmonary artery, while the aortic valve separates the left ventricle and the aorta. The right side of the heart pumps blood at a lower pressure into the pulmonary vasculature to be oxygenated. The left side of the heart pumps blood in the systemic circulation at a much higher pressure. Therefore the valves on the left side of the heart are subject to higher pressures. Diseases of the heart valves can be acquired or congenital. When the aortic valve is damaged at a young age most patients are considered for the Ross procedure.
Absolute contraindications :
Relative contraindication: (due to a higher risk of autograft dysfunction)
Equipment for this procedure includes but is not limited to the following: standard pneumatic sternal saw, oscillating sternal saw, cardiopulmonary bypass pump, potassium, cautery tool, surgical knife and blade, surgical retractor, right-angle clamp, surgical scissors, 4–0 and 5-0 polypropylene suture, and transthoracic echocardiogram.
A trained cardiothoracic surgeon, anesthesiologist, cardiologist, imaging specialist, surgical assistants/nursing, scrub/operating room technicians, and ancillary staff are recommended for a successful, safe procedure.
The primary goal in preparation for the Ross procedure along with any other surgical procedure is to achieve sterility. This means the chest needs to be shaved and sterilized, followed by placement of sterile drapes to allow access to the surgical field only once opening of the chest during the procedure has occurred. The Ross procedure is conducted under general anesthesia, and therefore pre-anesthetic evaluation and intubation for maintaining airway and sedation are utilized. Depending on the center and the operator, pre-operative and perioperative transesophageal echo may be performed.
Following a median sternotomy, the Ross procedure begins with standard exposure of the heart and the aorta followed by establishing cardioplegia and initiation of cardiopulmonary bypass. The ascending aorta is opened transversely about a centimeter above the origin of the right coronary artery (RCA). The aortic area is then inspected for any abnormalities that may prohibit surgical success. If no abnormalities are present, the main pulmonary artery (PA) is opened transversely proximal to the bifurcation. The pulmonary valve (PV) is then itself inspected for anomalies. Again if no abnormalities exist, then the valve replacement is performed using the full root approach. The full root approach is most commonly used about 90% of the time because it has the lowest risk of pulmonary autograft failure. In rare circumstances, depending on the anatomy, another approach may be a better choice, such as the sub-coronary, sub-coronary with retained noncoronary sinus, or cylinder approaches.
In this chapter, we describe the full root approach because it is the most commonly used method. The full root approach is begun by moving the root out of the surgical plane and pushed upwards. The posterior PA root is then cut to the muscle to visualize the right ventricular outflow tract (RVOT) through the incision. Next, the PA is separated from the aorta, and a clamp is then used to designate the most proximal area to the pulmonary valve. In the next step, an opening into the RVOT is created followed by dividing the anterior right ventricle and scoring the posterior muscle of the right ventricle partially. Following this, the pulmonary artery root is excised and separated. Next, removal of the aortic valve and root occurs after carefully cutting out the ostia with buttons from the native aorta.
Now the pulmonic autograft is anastomosed to the LVOT followed by reimplantation of the right and the left coronary arteries on to the autograft, followed by proximal anastomosis of the pulmonic autograft, and hemostasis is secured. In the next step, the PV allograft is anastomosed proximally and distally to complete the pulmonary circuit. A transesophageal echocardiogram is performed to verify valve function, and hemostasis is verified before weaning the patient off the cardiopulmonary bypass pump and completion of the procedure.
Potential complications with the Ross procedure include:
Multiple studies have shown that there is a durable, long-term clinical success from this procedure with an extremely low mortality rate. Because this procedure uses biological valves, it obviates the need for oral anticoagulation which would have otherwise been necessary for this particular group of patients because they would have needed mechanical valves.  The Ross procedure also eliminates the need for aortic valve replacement for up to as much as 10 years. This is probably due to two factors. One being that the autographed pulmonary valve in the place of the aortic valve has the ability to grow as the patient grows and the second being that there are lower pressures in the right side of heart creating for less stress on the pulmonary valve replacement and subsequently this leads to a reduced failure rate. Overall, this procedure is an excellent option for children and youth to improve survival. It remains to be the only operation that allows for aortic valve replacement with a living valve substitute.
The Ross procedure is major cardiovascular surgery, and it is imperative to utilize a heart team with patient-centric approach regarding the potential risks and benefits of undergoing this procedure. Such a complex procedure requires adequate planning and coordination between the various care providers. The enthusiasm for this procedure has varied over the last several decades with studies demonstrating lower mortality, bleeding, thromboembolism, endocarditis compared to mechanical valve replacement but with the need for higher risk of reintervention of the auto and allograft valves because of structural deterioration. Further, operator experience and expertize are essential for achieving excellent clinical outcomes, and therefore this procedure should be performed at high volume centers of excellence.
The American College of Cardiology/American Heart Association currently recommends Ross as a Class IIb while the Society for Thoracic Surgeons recommend this as a class III indication in patients needing aortic valve surgery. Because of the above recommendations, the utilization of the Ross procedure has been in decline. The emergence of transcatheter valve replacements for degenerating bioprosthetic valves which in the case of the Ross procedure are the auto and allografts are easily replaceable without the need for open heart surgery, and this may present a new lease of life for the Ross procedure. 
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