Donald Nixon Ross was born and educated in South Africa. Ross moved to London early in his career and became the foremost cardiac surgeon of the National Heart Hospital there until his retirement from that institution. He continues in private practice at the Harley Street Clinic. Like all other surgeons in the British system, he is addressed as Mr. Ross as opposed to Dr. Ross, the title "Mr." being a traditional label distinguishing surgeons from other medical specialists.

The idea of using a donor human valve to replace a diseased human valve was one of the first concepts in valvular heart surgery. Both Donald Ross in London and Sir Brian Barrett-Boyes in New Zealand successfully began implanting donor (cadaver) aortic valves in humans in 1962. There was concern about the long-term fate of these valves and the limited availability of appropriate donor valves was an obvious problem.

The idea of placing the pulmonary valve in the aortic root as an aortic valve was actually tried by Lower and Shumway (the great Stanford transplant pioneer) in dogs, and the technique was described by Gunning and Carlos Duran (another great valve surgeon) at Oxford. But it was Donald Ross in London who first performed this operation in a human being.

In 1967, Mr. Ross reported moving the pulmonary valve into the aortic position. (In the same report, he described putting it in the mitral position as well.) He called this operation the Pulmonary Autograft. The space left where the pulmonary was removed became a challenge to fill with a substitute that would last. He tried a lot of different things but finally decided on the homograft (human donor aortic or pulmonary valve) as the most durable.

Why perform a double valve operation when only a single valve is diseased? That was the fundamental question addressed by Donald Ross in the beginning. His answer then is still valid. If we can successfully and accurately implant the pulmonary valve in the aortic position, it can last for life. The problem valve then becomes the much less important pulmonary homograft in the low-pressure right side of the heart where the durability has been proven to be better, the consequences of failure are far less, and further surgery is easier if required. The slightly higher immediate risk of the bigger operation is an investment in a future free of restrictions without risk of blood clots or bleeding from blood thinners.

Ross believed the native pulmonary valve could be a permanent, living replacement for the aortic valve, and then the potentially problematic valve would be in the old pulmonary position. This, he reasoned, would be a problem better tolerated since the pressures there are so much lower. We now know that people can live well for many years with virtually no functioning pulmonary valve, and that regardless of the way a homograft is prepared or preserved, it lasts longer on the right side of the heart than on the left.

The problem remained that Ross had invented a technically demanding operation that converted a single valve operation into a double and still required that a homograft supply be available. Those two reasons kept the operation literally in his hands for almost 20 years. It was in 1986 in Oklahoma City at the University of Oklahoma Health Sciences Center that Ronald Elkins and Paul Stelzer picked up on this idea and tried to duplicate it in America.

After a few patients, Dr. Stelzer proposed that the operation could be modified into a full aortic root replacement much as was done with aortic homografts to reduce the incidence of regurgitation of the new valve. He believed if the three-dimensional architecture of the pulmonary valve could be left undisturbed in the native tube (the pulmonary root) and that tube become the new aorta, the valve would fare better.

The only problem was the additional challenge of disengaging the coronary arteries from the native aortic root and re-implanting them into the much thinner wall of the pulmonary root. In addition, the complete replacement of the aortic root with anything -- homograft, autograft, xenograft, or Dacron tube -- presents formidable risks of bleeding from all the needle-holes under high pressure at the end.

Dr. Stelzer first did this modified operation in March 1987. He described the technique and reported the results to the American Heart Association in the fall of 1988 - a report that was published in "Circulation" in November 1989. Unknown to Stelzer, Donald Ross had previously done this in about 10 patients when he was faced with an unsalvageable aortic root.

When Dr. Stelzer visited Mr. Ross in the summer of 1988 and told him about this modification, Ross showed him a catheterization film of a patient he had done seven years earlier that looked just like a normal aorta. When the file was examined to see what had been done, to their surprise, Ross had done the operation as a root replacement. It was great to see such a fine result had already been proven. As time has passed, the root replacement modification has become the standard method for doing the Ross Procedure.

In 1989 Dr. Stelzer returned to New York and began the slow process of introducing the new procedure to the East Coast. One of his earliest patients was a NYC physician who called Oklahoma looking for him, having learned about the operation. The patient was delighted to learn he could have it in New York where he continued to practice medicine until he was taken from his family by a diving tragedy just over 14 years after the successful "switch.".

Since 1993, Dr. James Oury maintained at the International Heart Institute of Montana an international registry of patients who have undergone the Ross Procedure. Over 4000 patients have been reported to the registry from more than 200 surgeons worldwide. The goal is to maintain contact with patients to document the long-term benefit of this surgery. This registry has been in transition recently as Dr. Oury has moved to South Dakota.