Reinforced Ross Procedure in an Adult - "Beating Heart Autograft Harvest"

This is a case involving a 28-year-old male patient with a history of bicuspid aortic valve and previous repair of aortic coarctation via left thoracotomy as a child, which involved the use of a left subclavian flap technique.

The patient presented with moderate aortic valve stenosis and dilated ascending aorta. Follow-up cardiac MRI showed continued increase in his ascending aorta diameter that now measured 4.9 cm. The decision was made to proceed with surgery. Discussion regarding aortic valve replacement options was carried out and it was felt that he was a good candidate for a Ross procedure.

The procedure was performed via a standard median sternotomy and normothermic cardiopulmonary bypass via aortic and bicaval cannulation. The autograft was harvested with electrocautery on a beating heart. It was then trimmed and sized proximally to determine the size of the Valsalva graft needed. We added 4 mm to the proximal pulmonary autograft. A 32 mm Valsalva graft was used, and the autograft was reimplanted inside the Valsalva graft and secured proximally using 3 running 5/0 prolene sutures. The graft was then everted, and the distal portion of the autograft was suspended in the distal portion of the Valsalva graft using three running 5/0 prolene sutures. The autograft valve was then saline tested, and the pulmonary valve seemed to be competent. It was then placed in cold saline.

The ascending aorta was then cross-clamped and antegrade cardioplegia was administered. We then transected the ascending aorta. The aortic valve cusps were resected, and coronary buttons were harvested. Due to the size mismatch between the autograft and the native aortic root, we elected to enlarge the root by using a combination of anterior and posterior enlargement techniques. The annulus was split anteriorly to the left of the right coronary artery following Konno-Rastan incision (mini-Konno), and split posteriorly along the commissure between the left and non-coronary sinuses of Valsalva following Manouguian’s technique. The reinforced autograft was then secured to the left ventricular outflow tract using multiple interrupted pledgeted 2/0 Ethibond sutures that were placed in a horizontal mattress fashion. Coronary artery buttons were then re-implanted in the middle of the corresponding sinus of Valsalva of the neo-aortic root using running 5/0 prolene sutures. These sutures incorporated all three layers (the autograft sinus wall, the hemashield graft and the native coronary button).

The distal Valsalva graft was then anastomosed to the native distal ascending aorta using running 4/0 prolene suture. The heart was then de-aired, and the aortic cross-clamp was removed. The patient regained his normal sinus rhythm. A 30 mm pulmonary homograft was then used to reconstruct the right ventricular outflow tract. The pulmonary homograft was a bit short, so we used a short segment of the 32 mm Valsalva graft to lengthen the pulmonary homograft. The patient was then weaned off cardiopulmonary bypass without difficulty. Post bypass transesophageal echocardiogram showed widely patent left and right ventricular outflow tracts with a competent pulmonary homograft valve and no neo-aortic valve regurgitation. Ventricular function was preserved. The aortic cross-clamp time was 84 minutes.

The patient was extubated in the operating room and the remaining postoperative course was uneventful. He was discharged on the sixth postoperative day.

In conclusion, the reinforced Ross procedure has the potential to be a better support design for the pulmonary autograft in young adult patients with aortic valve disease compared to the standard Ross, and this may have the potential for a longer-term durability of the neo-aortic valve and may decrease the incidence of neo-aortic root aneurysm formation. Long-term data will be needed.

References

1. Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet. 1967 Nov 4;2(7523):956-958.
2. El-Hamamsy I, Eryigit Z, Stevens LM, Sarang Z, George R, Clark L, et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomized controlled trial. Lancet. 2010 Aug 14;376(9740):524-531.
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

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