Dacron Graft Encased Modified Ross Operation

The pulmonary autograft operation was introduced by Donald Ross in 1967. Since then, the Ross operation has become a viable and durable option for aortic valve replacement in both the pediatric and adult populations (1). Pulmonary autograft dilatation is one of the complications noted in the adult population. Because of this, the Ross operation is showing a declining trend in this adult population. To prevent this complication, Ross Ungerleider came up with a simple and reproducible modification by adding a Dacron tube graft over the pulmonary autograft, and found no pulmonary autograft dilatation in 30 patients over the period of four years (2).

The concerns raised with the modified Ross procedure are that the Dacron tube graft is a cylindrical graft and the sinus portion of the autograft is essential for the normal functioning of the leaflets, as studied in valve-sparing aortic root replacement procedures and experimental studies, and the modified Ross procedure does not address and prevent the potential threat to the valve leaflets function in the long term (3). The pseudosinus creation in the Dacron graft is very important to decrease the stress and strain on the leaflets, so that it is closer to normal, as studied by K .Jane Grande-Allen et al (3).

Keeping this in mind, the author has made an additional modification to the modified Ross operation by removing the autograft sinuses, which were getting restricted by the cylindrical Dacron graft, and creating a pseudosinus/neosinus in the Dacron graft.

With these modifications to the modified Ross operation, the author hopes to take care of the pulmonary autograft dilatation at all three levels:

1. Annular level – The author sutures the autograft to the Dacron graft and then to the aortic annulus, which prevents annular dilatation.
2. Sinuses – By excising the native autograft sinuses, which are being restricted by the Dacron graft, and creating the pseudosinus/neosinus in the Dacron graft, the author hopes to preserve the valve leaflet function.
3. Sinotubular junction – Since the author is fixing the commissures to the Dacron graft and then suturing the Dacron graft to the ascending aorta, the dilatation at the sinotubular junction is nullified.

References

1. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. 1967;290(7523):956-958.
2. Ungerleider RM, Ootaki Y, Shen I, Welke KF. Modified Ross procedure to prevent autograft dilation. Ann Thorac Surg. 2010;90(3):1035-1037.