Fourth Sternotomy with Reinforced Ross Procedure

A twenty-year-old woman presented with a severe left ventricular outflow tract (LVOT) obstruction secondary to prosthetic aortic valve dysfunction. She was born with a bicuspid aortic valve and had undergone four previous operations: a left thoracotomy with left subclavian artery flap for repair of aortic coarctation and three sternotomies (resection of a subaortic membrane, resection of a recurrent subaortic membrane with open aortic valvuloplasty, and aortic valve replacement with a bioprosthesis) in addition to an ascending-to-descending bypass graft for recurrent aortic coarctation. She also underwent multiple balloon dilation and stent placement in her native aortic coarctation repair site. 

Preoperative workup showed a mean gradient of more than 40mmHg across the LVOT and possible narrowing in the proximal anastomosis of the aortic bypass graft. Under general endotracheal anesthesia, there was a 30mmHg gradient between the right upper and lower extremity arterial lines. A fourth-time sternotomy was performed using reoperative techniques without difficulty. Direct pressure measurements of the conduit pressure in relation to the upper and lower extremities arterial lines confirmed that there was an obstruction at the level of the proximal jump graft anastomosis and that revision was needed. Both the proximal aortic arch and the aortic jump graft were cannulated to ensure adequate lower body perfusion. 

The pulmonary autograft was then harvested on a beating heart and was placed inside a 28mm Valsalva graft. Then the aorta was cross-clamped, so as the jump graft proximal to its cannulation site. Next, the aortic bioprosthesis was explanted after harvesting both coronary arterial buttons. Because of a size mismatch with the LVOT, a mini-Konno incision was created. The reinforced autograft was secured to the LVOT using running three 4-0 polypropylene sutures. This was followed by reimplantation of the left coronary button. The distal pulmonary homograft (25mm in the current case) showed anastomosis to the native pulmonary bifurcation using a running 6-0 polypropylene suture. The posterior suture line of the distal aortic/autograft anastomosis was reconstructed, followed by reimplantation of the right coronary button. We used a 14mm Gelweave graft to reconstruct a new proximal ascending-to-descending bypass graft. This was sutured to the autograft/native distal aortic anastomosis. The heart was then de-aired, and the aortic cross-clamp was removed. The new 14mm graft was then tailored and sutured to the remaining portion of the previous aortic jump graft. 

The patient was weaned off cardiopulmonary bypass without difficulty. A post-bypass transesophageal echocardiogram showed competent neo-aortic and pulmonary homograft valves and a good biventricular function. There was also no difference between the upper and lower extremity arterial lines. The patient was then decannulated, and after hemostasis, the chest was closed in the standard fashion. The aortic cross-clamp time was 122 minutes, and the cardiopulmonary bypass time was 256 minutes. 

The patient was extubated in the operating room, received no transfusions, and was discharged on the fifth postoperative day. She continued to do well during her follow-up. 

References

1. Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet. 1967 Nov 4;2(7523):956-958.
2. Starnes VA, Bowdish ME, Cohen RG, Baker CJ, Elsayed RS.The Ross procedure utilizing the pulmonary autograft inclusion technique in adults. JTCVS Tech. 2021 May 31; 10: 372-376
3. David TE, Ouzounian M, David CM, Lafreniere-Roula M, Manlhiot C. Late results of the Ross procedure. J Thorac Cardiovasc Surg. 2019 Jan;157(1):201-208.
4. Liebrich M, Charitos EI, Dingemann C, Roser D, Seeburger J, Hemmer W, Voth V. The reinforced full-root technique for the Ross operation: surgical considerations and operative insights. Ann Cardiothorac Surg. 2021 Jul;10(4):485-490
5. Said, SM. The Ross-Konno procedure for congenital aortic stenosis. Ann Cardiothorac Surg. 2021 Jul;10(4):527-537. doi: 10.21037/acs-2021-rp-31.

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