Early 30s, 3 strokes over 7 years of On-X

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Hey guys, just wanted to post an update here.

Who I talked to:
I ultimately wound up getting other opinions - one useless one from a Stanford doc shortly after this post (I won’t even dive into it, it was a waste of time)

***and then a very comprehensive week long panel at the Mayo Clinic. I flew to Rochester MN for a week (and got trapped in a snowstorm trying to leave) but got a little more clarity on what’s potentially up, with the ultimate recommendation (they didn’t reach consensus at their conference but the majority opinion) of reoperation replacing the aortic root and valve. And my cardio there raised the Ross as an option while flagging that while he wouldn’t typically recommend it (for reasons known in this forum) it was worth discussing in my case.

The findings:

*Valve itself looks great. Zero evidence of thrombosis vegetation etc. There has never been any evidence of this in any of my multiple tests

*comprehensive CT scan revealed what the radiologist termed a limited Intimal tear in the aorta. Followed this up with another more directed TEE

*TEE clearly demonstrated the Intimal tear which can technically be termed an aortic dissection. Doc says likely happened during surgery in 2015. How fucking annoying is that? It is a very small tear but goes through the intima and somewhat into the media. Evidence that blood is collecting there and this seems to be what folks think has caused the strokes but again there was no 100% consensus. Doc said there was a patient who presented similarly, had root repair and did not have another stroke. This was not exactly a smoking gun, some folks have these tears and they don’t cause strokes. But in the absence of anything else…

*also found evidence of a small PFO (hole in septum that 30% of folks have) with the multiple echocardiograms they did and ultimately confirmed via TEE. Patching the PFO is a no brainer but seems unlikely to have caused the 3 strokes — my understanding is PFO doesn’t cause clots but just lets them pass over to go through the aorta. So wouldn’t explain why I had a stroke after being very anticoagulated. Also youd think I’d have had clot issues elsewhere which to my knowledge I’ve never had.

*also chatted with my estranged brother who - without valve disease - I learned had two different clot issues in his early 30s, one in lungs one in liver, a few years apart. After first clot was on Coumadin for 6 months was permitted to go off then had another one. No known cause, had hematology workups. Now on eliquis for a few years without issue. You’d think someone in my family would’ve mentioned this but better learning this late and having an additional data point 😂 this is something of a confounding data point for me because ⬇️

*a third (maybe fourth) repeat massive panel of blood work for anti clotting and everything else. My **** all looks great or as expected, nothing out of range.

Next steps:

*patch PFO (not a likely cause but this is a no brainer) think they’d do this during ohs if I get the valve replaced

*add plavix to my AC regimen

*ultrasound to confirm I don’t have evidence of clots elsewhere

*decide wtf to do next. Another on-X? Tissue valve? Ross? I am just not having a great time with this artificial valve, although I’ve still been waffling on whether to go tissue or mechanical - if the tear is what’s causing the issue then the valve is fine (as it has always appeared to be on the vast array of imaging across multiple media). But without consensus, and knowing my brother also has had random clot issues… imagine getting another on-X and having this issue recur again. Woof 👎🏼

To that end, cardio basically asked whether I’m more worried about stroke or reoperation. When I first answered this question at 25, I was more worried about reoperation. Three strokes later, very different calculus. Reoperation is not what gives me anxiety. Maybe it should. But losing brain function / part of my identity is a lot scarier to me at this point.

If I’m going with a tissue valve I’m thinking Ross because of the potential extra longevity, my relative youth, etc. Trying to book a consult at Sinai NY to discuss w the surgeon.

Anyway, that’s the lengthy update. Probably missed some stuff but think those are the high points. Thanks for listening 🙏🏽
 
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Hello,

I am really sorry to hear about your struggles.

I also considered the Ross when I got mine first done in my early 30s. But here are the fact on Ross reoperation (there are only two studies because this surgery isnt done that frequently).


Please have a look at
Outcomes of reoperations after Ross procedure - Stelzer- Annals of Cardiothoracic Surgery
and at

Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era - PubMed



The first study says: Survival exclusively following reoperation after Ross was 94.6% (86.1–97.9%) at one year, 87.4% (76.2–93.6%) at five years, 82.3% (68.9–90.4%) at ten years, and 77.5% (60.4–87.9%) at fifteen years (Figure 1A).

The Second study says: There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%).

From these studies it seems that medium term mortality after Ross reop is not low. Importantly, Ross surgeons argue that the risks are not as high at experienced Ross reop centers. But the first of these Studies was by a surgeon that did the most Ross ops in the US and the second by people at the Mayo clinic.

I get that this makes your decision harder and you are in a very difficult spot, but having all of this information before you make a decision is probably better than not having it at all.

Good luck in your decision.
 
Hello,

I am really sorry to hear about your struggles.

I also considered the Ross when I got mine first done in my early 30s. But here are the fact on Ross reoperation (there are only two studies because this surgery isnt done that frequently).


Please have a look at
Outcomes of reoperations after Ross procedure - Stelzer- Annals of Cardiothoracic Surgery
and at

Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era - PubMed



The first study says: Survival exclusively following reoperation after Ross was 94.6% (86.1–97.9%) at one year, 87.4% (76.2–93.6%) at five years, 82.3% (68.9–90.4%) at ten years, and 77.5% (60.4–87.9%) at fifteen years (Figure 1A).

The Second study says: There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%).

From these studies it seems that medium term mortality after Ross reop is not low. Importantly, Ross surgeons argue that the risks are not as high at experienced Ross reop centers. But the first of these Studies was by a surgeon that did the most Ross ops in the US and the second by people at the Mayo clinic.

I get that this makes your decision harder and you are in a very difficult spot, but having all of this information before you make a decision is probably better than not having it at all.

Good luck in your decision.
Thank you and thanks for sharing. I was overwhelmingly in favor of mechanical but if I’m not considering that and just looking at tissue vs Ross, given I am really indexing on minimizing stroke risk, it feels like it’s worth serious consideration.

I’ve been trying to read the studies and it’s hard for me to form a conclusive opinion given my medical and general ignorance. Each suggested article seems to contradict the last… For example Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study - PubMed
 
I’ve been trying to read the studies and it’s hard for me to form a conclusive opinion given my medical and general ignorance. Each suggested article seems to contradict the last… For example Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study - PubMed
The study which you cited is the one that Cryolife uses to promote the Ross. Surgeons who favor the Ross also cite this study.

Here is what they conclude:

"Long-term survival and freedom from reintervention were comparable between the Ross procedure and mechanical AVR. However, the Ross procedure was associated with improved freedom from cardiac- and valve-related mortality and a significant reduction in the incidence of stroke and major bleeding. "

But, the problem is that the mean follow up time was only 14.2 years. This is really something to think about. Apparently, they consider this a long term study. However, this study is not long enough to reach the years where the Ross causes problems for people. The pulmonary valve, transplanted to the aortic position, generally fails at about 20 years, if you are fortunate. The patient's pulmonary valve is replaced with a donor valve, which usually lasts a little longer, but will probably need replacement by 25 years for most people. A 32 year old patient, I would hope, would not be just looking 14 years ahead. If that was all one cared about, then the Ross may be an excellent choice. But, add 20 years to 32 and the patient is only 52 years old, and now the multiple reoperations begin. For most, a few years after the aortic is replaced, the pulmonary will need replacement, and the patient will likely still be in their 50s. So, that would be number 3 if the Ross was #1, and if the Ross was #2 or #3 for them, do the math. Even if the Ross was #1, the patient is facing a large number of reops in their lifetime, which will begin for most after 20+ years. So, I would put very little stock in a Ross study that only went out 14 years.

Those who promote the Ross will tell you that you can just go TAVR for aortic replacement and TPVR for the pulmonary when that time comes and just go through your leg with no OHS. It is troubling that they seem to be promising people this. There is no way that eligability for a TAVR or TPVR is a certainty. And, if you are qualified, do you really want to be in your early 50s and get a TAVR? The patient would still be young and would likely go through a standard tissue valve relatively quickly. There is not much data on how long TAVR last for young patients, but I was told by UCLA that I should expect about 5 years if I got one at 53. And, after the TAVR valve suffers SVD and needs replacement, one faces a procedure which bears significantly more risk than a standard valve operation. And, let's not forget that there would be a TPVR valve in play as well, which might last a little longer than the aortic TAVR, but, still will need replacement.
 
That’s helpful context, thanks for explaining.

Those outcomes still seem potentially better than just a tissue valve, right? Trying to game out what is best if mechanical is not an option
 
Those outcomes still seem potentially better than just a tissue valve, right? Trying to game out what is best if mechanical is not an option
It is not an easy choice, but if mechanical was off the table, I would give a lot of consideration to going with a Resilia Inspiris in the aortic position. It will mean reoperations, but you will be keeping the problem a one valve problem instead of turning a one valve problem into a two valve problem. We don't know yet if the anti-calcification treatment of the Resilia will add much to the expected durability, but at this point the data looks good. There is a real posibility that it will last 15 to 20 years in the aortic position, perhaps as long as the aortic valve after the Ross Procedure.

The other option I would consider is to look into which clinics are doing homografts. This is where a donor valve is placed in the aortic position. Studies show that these donor valves last about 20 years, similar to the transplanted pumonary valve into the aortic position in the Ross. But, this keeps the problem a one valve problem instead of a two valve problem. Pellicle had a homograft as a 28 year old, and it lasted him 20 years. They had to go back in for another reason at that time. His aortic valve was still doing ok, but they changed it out with a mechanical while they had him opened, to avoid needing another OHS in a few years.
 
Regarding the Ross, this operation is quite controversial as a first surgery. I think that most of these studies have been done on people that had Ross as a first operation. There isnt that much known what happens when the Ross comes as a second surgery (at least not from studies, since so few people have this as a second operation). I would ask your medical team if that raises the operative and complication risks relative to Ross as a first surgery (I think that is a fair question that needs to be answered).

If you dont want a mechanical valve, there are two choices:

1) Aortic Homograft - This can potentially last 20 years if done well. In Germany, they have now introduced 'tissue-engineered' homografts which in theory could last a lot longer, but there is only up to 5 years data so far (so not very long). However, I would have though that in your case, the homograft seems like a very good solution. So perhaps you should find a surgeon that has a lot of experience with this.

2) Tissue valve. I would go with Inspiris Resilia valve. This valve has been designed to get receive a TAVI (via some sort of clever mechanism). Lets say this valve lasts 10-15 years in you (normally you would get 8-12 out of a tissue, but I added years to account for new anticalcification treatment). Then you get a TAVR. This will give another 5-7 years. So you get 15-20 years out of one Aortic valve operation. There are uncertainties around whehter a TAVR will be possible when it comes to it. However, getting 15-20 years out of a tissue valve and having only one 'construction site (only aortic)', rather than two construction sites (as in Ross), would to me personally seem like a better risk/reward. But that is just my personal view.

Finally, one more thing to keep in mind, I think this is important:

They have recommended that you get an Aortic root and valve replacement. If you get a tissue valve and Aortic root replacement, there is a 20-30% chance that at the next re-op they will need to re-replace the root. Re-replacing the root at redo surgery is a higher risk intervention (think 3-5% mortality) than redo aortic valve surgery. This is something you should be aware of. Personally, I got a root replacement and tissue valve first time around at 32. This lasted 8 years. When I had my reop, my surgeon, who is a very experienced reop specialist, gave me only a 70% chance that he would be able to leave the root in tact and only replace the valve with a mechanical.

I know, lots of info to digest, but better to know now than after Operation.





Thank you and thanks for sharing. I was overwhelmingly in favor of mechanical but if I’m not considering that and just looking at tissue vs Ross, given I am really indexing on minimizing stroke risk, it feels like it’s worth serious consideration.

I’ve been trying to read the studies and it’s hard for me to form a conclusive opinion given my medical and general ignorance. Each suggested article seems to contradict the last… For example Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study - PubMed
 
1) Aortic Homograft - This can potentially last 20 years if done well.
agreed, for what its worth this is the data from my hospital.

Entrez PubMed
J Heart Valve Dis. 2001 May;10(3):334-44; discussion 335.
Related Articles, Links​

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

O'Brien MF, Harrocks S, Stafford EG, Gardner MA, Pohlner PG, Tesar PJ, Stephens F.

The Prince Charles Hospital and the St Andrew's Hospital, Brisbane, Queensland, Australia.

BACKGROUND AND AIM OF THE STUDY: The study aim was to elucidate the advantages and limitations of the omograft aortic valve for aortic valve replacement over a 29-year period.
...
Freedom from reoperation for structural deterioration was very patient age-dependent.
For all cryopreserved valves, at 15 years, the freedom was
* 47% (0-20-year-old patients at operation),
* 85% (21-40 years),
* 81% (41-60 years) and
* 94% (> 60 years).

I suspect the trend up at >60 is influenced by people over 60 dying before 15 years.

Myself I got around 20 years and my reoperation wasn't because of SVD but because of an Aneurysm (something quite common eventually in BAV patients and an independent risk factor to valve choice.

My advice to anyone is "keep it simple", not least because there is less to go wrong. Ross is about as far away from KISS as you get.

Best Wishes

PS, from a search on Dr Stafford's papers as found in one of he above links, if you're considering a Ross you should be across this (so you know they're not smoke and mirroring you).

https://pubmed.ncbi.nlm.nih.gov/2679469/
 
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Fascinating. Had no idea that likelihood of re-replacing the root was so high and added another few % of risk.

Also had no idea about the inspiris resilia valve. I’ll ask about this and the cryopreserved valves. On the resilia — In a perfect world where they could do valve in valve in valve that would get you some serious mileage.
 
I'm in the process of gathering information before I have my redo surgery. I'm headed back for further consultation with my first surgeon that I spoke to. I want to mention that the second opinion said that his plan would be to avoid a full root redo but to make an incision in the non-coronary sinus to "widen" the annulus. But there was also a concern of the exact placement of the circumflex artery and possibly having to readjust as well. I'm loaded with more questions going back to my original surgeon, second consult.

EDIT: these discussions with surgeons have been regarding bioprothstetic valves.

BCAR I don't know how comfortable you are with divulging more information regarding your visit to Stanford but I, for one, am very interested. They are on my list of possible surgery locations. They did my first procedure 20 years ago. You could always PM if more comfortable with that approach. Thanks.
 
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The stats on 20-30% replacement came from my surgeon, who did my second surgery, and 60% of his cases are redo's (He apparently redid someone's aortic valve for the 6th time successfully at one point). He said that sometimes the calcification gets in the way of cutting out the bio valve. On the other hand, the surgeon who did my first surgery said this would be my one and only root replacement and said that he changing the valve later is easy (to be fair to him, he wasnt much experienced in redo root surgery).

As for the root redo data:
https://pubmed.ncbi.nlm.nih.gov/22914250/
You can see this study quotes 6% operative mortatility for a root redo.

Compare this to the less than 1% chance of risk at first and then 1.5% of risk subsequent surgeries (See euroscore calculator below):
https://www.euroscore.org/index.php?id=17&lang=en
Good luck with your decision

One more thing: TAVI isnt a risk free procedure. Everytime they do a TAVI there is a higher risk of pace maker. Also, valve in valve in valve is probably the absolute max that can be done in your age group, since everytime the valve becomes smaller, your hearts output is lower and you can do less active stuff.

Again, more info better and best to discuss all of these concerns with your medical team.




Fascinating. Had no idea that likelihood of re-replacing the root was so high and added another few % of risk.

Also had no idea about the inspiris resilia valve. I’ll ask about this and the cryopreserved valves. On the resilia — In a perfect world where they could do valve in valve in valve that would get you some serious mileage.
 
Hey guys, just wanted to post an update here.

Who I talked to:
I ultimately wound up getting other opinions - one useless one from a Stanford doc shortly after this post (I won’t even dive into it, it was a waste of time)

***and then a very comprehensive week long panel at the Mayo Clinic. I flew to Rochester MN for a week (and got trapped in a snowstorm trying to leave) but got a little more clarity on what’s potentially up, with the ultimate recommendation (they didn’t reach consensus at their conference but the majority opinion) of reoperation replacing the aortic root and valve. And my cardio there raised the Ross as an option while flagging that while he wouldn’t typically recommend it (for reasons known in this forum) it was worth discussing in my case.

The findings:

*Valve itself looks great. Zero evidence of thrombosis vegetation etc. There has never been any evidence of this in any of my multiple tests

*comprehensive CT scan revealed what the radiologist termed a limited Intimal tear in the aorta. Followed this up with another more directed TEE

*TEE clearly demonstrated the Intimal tear which can technically be termed an aortic dissection. Doc says likely happened during surgery in 2015. How fucking annoying is that? It is a very small tear but goes through the intima and somewhat into the media. Evidence that blood is collecting there and this seems to be what folks think has caused the strokes but again there was no 100% consensus. Doc said there was a patient who presented similarly, had root repair and did not have another stroke. This was not exactly a smoking gun, some folks have these tears and they don’t cause strokes. But in the absence of anything else…

*also found evidence of a small PFO (hole in septum that 30% of folks have) with the multiple echocardiograms they did and ultimately confirmed via TEE. Patching the PFO is a no brainer but seems unlikely to have caused the 3 strokes — my understanding is PFO doesn’t cause clots but just lets them pass over to go through the aorta. So wouldn’t explain why I had a stroke after being very anticoagulated. Also youd think I’d have had clot issues elsewhere which to my knowledge I’ve never had.

*also chatted with my estranged brother who - without valve disease - I learned had two different clot issues in his early 30s, one in lungs one in liver, a few years apart. After first clot was on Coumadin for 6 months was permitted to go off then had another one. No known cause, had hematology workups. Now on eliquis for a few years without issue. You’d think someone in my family would’ve mentioned this but better learning this late and having an additional data point 😂 this is something of a confounding data point for me because ⬇️

*a third (maybe fourth) repeat massive panel of blood work for anti clotting and everything else. My **** all looks great or as expected, nothing out of range.

Next steps:

*patch PFO (not a likely cause but this is a no brainer) think they’d do this during ohs if I get the valve replaced

*add plavix to my AC regimen

*ultrasound to confirm I don’t have evidence of clots elsewhere

*decide wtf to do next. Another on-X? Tissue valve? Ross? I am just not having a great time with this artificial valve, although I’ve still been waffling on whether to go tissue or mechanical - if the tear is what’s causing the issue then the valve is fine (as it has always appeared to be on the vast array of imaging across multiple media). But without consensus, and knowing my brother also has had random clot issues… imagine getting another on-X and having this issue recur again. Woof 👎🏼

To that end, cardio basically asked whether I’m more worried about stroke or reoperation. When I first answered this question at 25, I was more worried about reoperation. Three strokes later, very different calculus. Reoperation is not what gives me anxiety. Maybe it should. But losing brain function / part of my identity is a lot scarier to me at this point.

If I’m going with a tissue valve I’m thinking Ross because of the potential extra longevity, my relative youth, etc. Trying to book a consult at Sinai NY to discuss w the surgeon.

Anyway, that’s the lengthy update. Probably missed some stuff but think those are the high points. Thanks for listening 🙏🏽
Considered the potential for air embolus thru pfo causing a cva?
 
Considered the potential for air embolus thru pfo causing a cva?
I don’t think anyone specifically mentioned that as a potential vector for the three strokes, and that’s the first I’ve heard of it. Is that mostly an immediate post surgery concern?
 
Person can get it when doing scuba diving. Knew a lady that would get decompression sickness with minimal depth underwater. She kept getting bent so she went thru work up and found she had a pfo. It was patched and now she enjoys diving all the time without having to worry about getting the bends at recreational dive limits (Max depth 120 ft on compressed air). I have no idea if being on the bypass pump could cause something like that. Gas physiology is fascinating subject.
 
The study which you cited is the one that Cryolife uses to promote the Ross. Surgeons who favor the Ross also cite this study.

Here is what they conclude:

"Long-term survival and freedom from reintervention were comparable between the Ross procedure and mechanical AVR. However, the Ross procedure was associated with improved freedom from cardiac- and valve-related mortality and a significant reduction in the incidence of stroke and major bleeding. "

But, the problem is that the mean follow up time was only 14.2 years. This is really something to think about. Apparently, they consider this a long term study. However, this study is not long enough to reach the years where the Ross causes problems for people. The pulmonary valve, transplanted to the aortic position, generally fails at about 20 years, if you are fortunate. The patient's pulmonary valve is replaced with a donor valve, which usually lasts a little longer, but will probably need replacement by 25 years for most people. A 32 year old patient, I would hope, would not be just looking 14 years ahead. If that was all one cared about, then the Ross may be an excellent choice. But, add 20 years to 32 and the patient is only 52 years old, and now the multiple reoperations begin. For most, a few years after the aortic is replaced, the pulmonary will need replacement, and the patient will likely still be in their 50s. So, that would be number 3 if the Ross was #1, and if the Ross was #2 or #3 for them, do the math. Even if the Ross was #1, the patient is facing a large number of reops in their lifetime, which will begin for most after 20+ years. So, I would put very little stock in a Ross study that only went out 14 years.

Those who promote the Ross will tell you that you can just go TAVR for aortic replacement and TPVR for the pulmonary when that time comes and just go through your leg with no OHS. It is troubling that they seem to be promising people this. There is no way that eligability for a TAVR or TPVR is a certainty. And, if you are qualified, do you really want to be in your early 50s and get a TAVR? The patient would still be young and would likely go through a standard tissue valve relatively quickly. There is not much data on how long TAVR last for young patients, but I was told by UCLA that I should expect about 5 years if I got one at 53. And, after the TAVR valve suffers SVD and needs replacement, one faces a procedure which bears significantly more risk than a standard valve operation. And, let's not forget that there would be a TPVR valve in play as well, which might last a little longer than the aortic TAVR, but, still will need replacement.
Why should cyrolife promotes ROSS? They are the seller for On-X as well

https://www.cryolife.com/
 
Thank you and thanks for sharing. I was overwhelmingly in favor of mechanical but if I’m not considering that and just looking at tissue vs Ross, given I am really indexing on minimizing stroke risk, it feels like it’s worth serious consideration.

I’ve been trying to read the studies and it’s hard for me to form a conclusive opinion given my medical and general ignorance. Each suggested article seems to contradict the last… For example Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study - PubMed
I think to what you said about this...>>>"form a conclusive opinion given my medical and general ignorance. " part of what you stated, its a larger club then some of us even think about, and I am a member of for just about my entire 70years! I try and although no matter what I do, most of what I should and need to comprehend, I do not! It goes as it were, right over my head!

But as I have said here and recently, this is why this PLACE here, and is perhaps just a small part of social media, it happens to be for most of us, a very important part, and it helps in a very awesome way for me any how, to understand more then I would without it, I understand that, and very much appreciate this fact!
Point being then i think is, dont feel that you are alone in trying to figure this all out, and this place and all of these wonderful folks that share is now, and has become part of a whole, instead of what the Medical Practitioners, etc., part usta be all by itself!
Sorry to hear about what you are going thru, and wish you luck with whatever you decide to do, and wish the best outcome for you all!
[what troubles me about all of this is, there are so many that do not use this place, and for whatever reason....shy, introvert, antisocial. But for anyone to not come here, or anywhere, and ask anything because they think their question is stupid or whatever, the only stupid question/s are the ones that are not presented so others may reply. [I hope that came out as I intended, and anyway, its the thought that counts, right? So please, if you have anything troubling you about something, or anything concerning things that are talked about here, do not hesitate, please ask anything and everything!!!]

{{{rant finished, hope I did not offend anyone!}}}
 
You will notice that this is nothing short of a strong promotion, basically an advertisement, for the Ross Procedure.

https://www.cryolife.com/avr/the-ross-procedure/
I find this interesting:
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923
under:

Recommendation-Specific Supportive Text​

point 6

The failure of the Ross procedure is most often attributable to regurgitation of the neoaortic valve in the second decade after the operation. In addition, at least half of pulmonic homograft valves require reintervention within 10 to 20 years. Calcification of the homograft and adhesions between the homograft and neoaorta may increase the difficulty of reoperation. The Ross procedure typically is reserved for younger patients with appropriate anatomy and tissue characteristics for whom anticoagulation is either contraindicated or undesirable, and it is performed only at Comprehensive Valve Centers by surgeons experienced in this procedure

Firstly I'd ask how well people actually understand anticoagulation, and what specifically "undesirable" means in reality. Next seldom do I see Homograft promoted as heavily as The Ross, which is shown to get closer to the 20 years and only operates on the diseased valve (the aortic valve) and doesn't touch the others and avoids ACT as much as the Ross does.

If the principle is "minimise harm" I'm not sure how the Ross qualifies for that.

Perhaps that's not on the Cryo Life schedule?
 

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