A Rare Open-Heart Procedure Is the Best Option for Certain Heart Diseases. This Philly Surgeon Is One of the Few With the Skill to Perform It.

When we think of heart surgery, we often think of last-minute, life-saving interventions. Operating on the heart is challenging and complex, so it’s not undertaken lightly. But heart surgery can also be used to create a positive transformation in someone’s life, as well as lower the risk of a later cardiac event, making it worth the big decision to pursue treatment. And as the techniques of heart surgery continue to move forward, the most advanced heart surgeons are helping patients move beyond a life full of struggling to perform basic tasks, to a life lived without having to think twice about going up a set of stairs. In other words, heart surgery can help patients live life unimpaired. 

One of the leaders of that effort is at work right here in Philadelphia. Dr. Yoshiya Toyoda, chief of cardiovascular surgery at Temple University Hospital, is an innovator in the application of the Ross procedure. This technique is used to treat aortic valve disease, a condition that results from a damaged aortic valve in the heart, commonly as a result of a birth defect, and can eventually make simply getting around the house difficult.

“The Ross procedure, among the options for treating the disease, is the only one that provides patients with survival similar to the general population,” Toyoda says. “It’s a great procedure for young, active patients.”

The Ross procedure is also critical because aortic valve disease can not only cause immediate cardiovascular symptoms such as shortness of breath, but can, in the long-term, lead to a serious cardiac event, such as a stroke or cardiac arrest. The procedure relieves patients of these symptoms and risks, allowing them to live life normally for a period of up to twenty years without another procedure. And in that sense, the Ross procedures makes daily life easier to live and can be life-saving at the same time. 

However, the complexity of the surgery has made it so that the procedure is not widely adopted among cardiac surgeons. Even today, only a small number of surgeons nationwide perform the procedure. But as physicians like Toyoda make new innovations to the procedure to increase its efficiency and safety, its gaining mainstream adoption. And increasingly, it’s becoming the preferred option for those patients who want to live life free of limitations. 

The Best Option

There are multiple solutions for treating aortic valve disease. But some alternatives tend to have downsides. 

Mechanical valves and valves created from cow or pig tissue are more common, but require serious, lifelong medications to function–and these procedures also need to be redone every several years. 

“The anticoagulation medication patients have to take can also result in serious bleeding complications over time,” Toyoda says. 

Avoiding those complications altogether is the key innovation of the Ross procedure. The technique uses what’s called an “autograft.” The pulmonary valve, a mirror image of a normal aortic valve, is taken from the patient’s heart, and used to replace the damaged aortic valve. A donor human pulmonary valve then replaces the removed pulmonary valve. 

The autograft holds up better in the body because it’s taken from the patient’s own body, meaning there’s no need for medication, and the valve lasts longer. It’s especially effective for physically active patients, as the valve can expand and contract more naturally than an artificial valve, allowing for unimpaired cardiovascular activity. This quality also makes it ideal for pregnant patients, as it can handle the increased cardiovascular strain caused by pregnancy. For younger patients, it can even grow along with the rest of the body. 

The donor valve, in turn, holds up well in its own position because the location of the pulmonary valve requires less blood pressure, minimizing the stress placed on the donor valve.

Making It Possible

Of course, replacing two different valves in one procedure requires a much more complex surgery. And that’s where the talent and innovations of leading surgeons like Toyoda become critical. 

Toyoda’s work begins long before the operating room. Because the surgery is more taxing on the human body, patient selection for the procedure is a skill in and of itself. Accordingly, Toyoda tests the function of critical organs that could be affected by the strain of the procedure. He also works with patients to identify potential complications–like conditions that cause bleeding–to help ensure the best possible outcomes for each unique case. 

The nature of the procedure also requires interrupted blood flow to the heart, while valves are being replaced. The heart’s recovery depends on minimizing this time, so a surgeon needs to have fully mastered performing both types of valve procedures as quickly as possible. 

“The shorter cross-clamp time the better,” Toyoda says. “My cross-clamp times are generally shorter than the times reported by other centers performing the procedure around the world,” which can mean faster, fuller recoveries.

Toyoda’s innovations have been transformational. In increasing the efficiency of the procedure–through techniques such as harvesting the autograft prior to clamping the aorta–he’s increased the viability of the procedure, making it more accessible for more physicians and patients. Recently, his research has shown that his use of the Ross procedure also decreases the risk of reinfection, as compared to a prosthetic valve.

“I look for an opportunity to improve every time I do the procedure,” Toyoda says. 

Creating an Impact

Even as the Ross procedure has become more popular, it’s often limited to high-profile and urgently needed cases–a famous example is Arnold Schwarzenegger, who received the surgery in 1997 and did not require reoperation for 21 years. But thanks to innovations driven by physicians like Toyoda, the procedure is gaining popularity and has become recommended by the American Heart Association as a solution for aortic valve disease. 

That’s important because the technique can make a world of difference in individual lives. Toyoda points to one of his recent cases: A young woman in her early 40s who was experiencing declining exercise tolerance, fatigue and shortness of breath. More concerningly, she had been diagnosed with a heart murmur and severe aortic stenosis, causing her to require anti-hypertensive medication. 

She did not want to receive multiple repeated surgeries or take life-long medication, so she didn’t want to receive an artificial valve. That’s why she sought Toyoda’s help. And after the Ross procedure, she’s made a full recovery.

“She returned to normal activity without shortness of breath or fatigue, and she is not taking any blood thinner,” Toyoda says.

As physicians like Toyoda lead education for other surgeons on applying the technique, and the procedure becomes more available to patients, Toyoda predicts that this kind of result will increase. Eventually, the procedure could become a go-to for patients looking for long-term positive effects like these. 

“In the future, as research continues, the American Heart Association may increase its recommendation,” he says. “And fortunately, there are more training courses and conferences now to educate interested surgeons … For the young active patient, this is the best procedure.”