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MP 7.01.64 Ross Pulmonary Autograft

Medical Policy
Section
Surgery
Original Policy Date
4/1/98
Last Review Status/Date
Reviewed with literature search/3:2003
Issue
3:2003
Return to Medical Policy Index


Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Ross pulmonary autograft refers to a procedure in which the pulmonic valve is substituted for the diseased aortic valve, while a homograft prosthetic valve replaces the pulmonic valve. This procedure was first devised in 1967 and sought to provide a permanent aortic valve substitution that would not degenerate like a homograft valve and would not require chronic anticoagulation therapy like a prosthetic valve. The risk benefit ratio involves a balance between a more complicated surgical procedure (essentially a double valve replacement) and a potentially more durable and physiologic aortic valve replacement. Furthermore, it is thought that the autografted pulmonary valve will grow with the young patient, thus obviating the need for reoperation. For these reasons, the Ross procedure has been considered most appropriate for young adults.

In addition, Ross pulmonary autografting may be used as a component of an aortoventriculoplasty procedure in young patients with complex left ventricular outflow tract obstruction. This procedure may be referred to as the Ross-Konno procedure.


Policy

The Ross pulmonary autograft may be considered medically necessary as an alternative for aortic valve replacement in patients with congenital malformations of the aortic valve or in those with acquired aortic valve disease.


Policy Guidelines

No applicable information


Benefit Application

BlueCard/National Account Issues

This is a specialized procedure that may require out of network referral.


Rationale

In 1997, Ross reported the results on long-term follow-up (up to 20 years) of 131 recipients of a pulmonary autograft. (1) Ten and 20 years after the surgery, survival was 85% and 61%, respectively, while freedom from autograft replacement was 88% and 75%, respectively. The authors concluded that the capacity of the autograft to maintain viability with minimal degeneration was unmatched by other biologic valve replacements.

Although the procedure was pioneered and performed most frequently in England, its acceptance by American cardiovascular surgeons has been growing in this country. The technique has also been adapted for replacement of the aortic root with a pulmonary autograft (2), or as a component of an extended aortic allograft root replacement (e.g., Konno procedure) in patients with complex left biventricular outflow obstruction. (3)

2003 Update
 
A literature search based on the MEDLINE database was performed for the period of 1998 through June 2003. No literature was identified that would prompt reconsideration of this policy; therefore, the policy statement is unchanged. The published literature primarily consists of large case series from single institutions that continue to report favorable results with the Ross pulmonary autograft procedure. (4-9)

References:

  1. Chambers JC, Somerville J, Stone S et al. Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series. Circulation 1997; 96(7):2206-14.
  2. Kouchoukos NT, Davila-Roman VG, Spray TL et al. Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic-valve disease. N Engl J Med 1994; 330(1):1-6.
  3. Reddy VH, Rajasinghe HA, Teitel DF et al. Aortoventriculoplasty with the pulmonary autograft: the “Ross-Konno” procedure. J Thorac Cardiovasc Surg 1996; 111(1):158-67.
  4. Bohm JO, Botha CA, Hemmer W et al. Older patients fare better with the Ross operation. Ann Thorac Surg 2003; 75(3):796-802.
  5. Takkenberg JJ, Dossche KM, Hazekamp MG et al. Report of the Dutch experience with the Ross procedure in 343 patients. Eur J Cardiothorac Surg 2002; 22(1):70-7.
  6. Paparella D, David TE, Armstrong S et al. Mid-term results of the Ross procedure. J Card Surg 2001; 16(4):338-43.
  7. Elkins RC, Lane MM, McCue C. Ross operation in children: late results. J Heart Valve Dis 2001; 10(6):736-41.
  8. Laudito A, Brook MM, Suleman S et al. The Ross procedure in children and young adults: a word of caution. J Thorac Cardiovasc Surg 2001; 122(1):147-53.
  9. Pessotto R, Wells WJ, Baker CJ et al. Midterm results of the Ross procedure. Ann Thorac Surg 2001; 71(5 suppl):S336-9.

 

Codes

Number

Description

CPT 

33413 

Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) 

ICD-9 Procedure 

35.21 

Replacement of aortic valve with tissue graft 

 

35.22 

Other replacement of aortic valve 

 

35.33 

Annuloplasty 

 

39.61 

Extracorporeal circulation auxiliary to open heart surgery 

ICD-9 Diagnosis 

424.1 

Aortic valve disorders 

 

746.3 

Congenital stenosis of aortic valve 

 

746.4 

Congenital insufficiency of aortic valve 

 

746.89 

Other specified anomalies of heart 

 

746.9 

Unspecified anomaly of heart 

HCPCS 

No code 

Type of Service 

Surgery 

Place of Service 

Inpatient 


Index

Aortic valve replacement, pulmonary autograft
Pulmonary autograft
Ross pulmonary autograft


Policy History

Date Action Reason
04/1/98 Add to Surgery section New policy
04/15/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy reviewed with literature search; no change in policy statement.


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