Patients with Marfan’s Syndrome should NOT be treated with the Ross Procedure. The reason is the hereditary weakness of the aortic wall (fibrillin defect) that extends to the pulmonary wall as well. This might be supported with external Dacron grafting, but is generally considered a contra-indication to the Ross.
Patients with acute rheumatic fever as the cause of their aortic valve problem should have this thoroughly treated and controlled before considering the Ross Procedure. Those patients in whom the operation has been done early in the course of the disease have rapidly developed rheumatic valvulitis of the pulmonary autograft causing it to fail and require replacement. This has been demonstrated in Saudi Arabia and India where rheumatic fever is still a common problem compared to the United States.
Patients with auto-immune disorders such as Systemic Lupus Erythematosis or Juvenile Rheumatoid Arthritis may develop antibodies that attack the autograft valve and cause it to fail although the Ross Procedure has been successful in both of these conditions in carefully selected patients.
Patients with bleeding disorders such as ITP are at higher risk for bleeding during this complex surgery, but they are also at increased risk for anticoagulation, so this decision must be carefully individualized.
Patients with immediately life-threatening destruction of the aortic valve and root by infection (endocarditis) may be better served by a simpler, faster operation with less complexity. However, if infection is less severe or limited to the leaflets alone and a planned operation can be organized, the Ross Procedure can be considered especially in the very young patient in whom the other tissue alternatives are of such limited durability.
If a mechanical valve is already present in the mitral position or in whom repair is not possible and mechanical valve is chosen for the mitral, there is clearly a need for life long Coumadin. In that setting, the logical choice for the aortic valve is another mechanical valve.