Reoperative Valve-Sparing Root Replacement and Pulmonary Homograft Reconstruction of RVOT Following Pediatric Ross Procedure

The ideal aortic valve (AV) substitute for patients with AV disease remains under debate. In select patients in whom valve durability is of particular importance, the Ross procedure, when performed at high-volume centers, results in excellent long-term survival and favorable valve durability and freedom from valve-related reinterventions (1). In the pediatric population, however, aneurysmal growth and dilatation of the autograft continues to plague outcomes (2).

The authors present the case of an 18-year-old man with a unicuspid AV who underwent a Ross procedure at age three for endocarditis. He presented fifteen years later with easy fatiguability, and workup revealed aneurysmal dilatation of the aortic root with moderate aortic insufficiency (AI) and pulmonary homograft stenosis. To rebuild the autograft root without sacrificing his living neo-aortic valve, a valve-sparing root replacement (VSRR) with cusp repair was performed.

Following a reoperative median sternotomy and cardioplegic arrest, the dilated and elongated neo-aortic root was liberated from the right atrium down to the left atrial roof, as well as from the pulmonary homograft. The calcified homograft tissue was excised. Attention was then directed to the neo-aortic root. There was ample leaflet depth and the native annulus measured 24 mm, negating the need for annular stabilization. Following mobilization of the coronary arteries, the excess dilated sinus tissue was resected from the sinuses, leaving ~5 mm of autograft wall along the top of the leaflets. A 30-mm Hemashield graft was chosen after sizing of the three suspended commissures. The left sinus limb of the graft was then attached along the left coronary sinus with continuous 5-0 Prolene, ending at the top of the commissure at either end; this nestled the graft inside the residual autograft root tissue. The right sinus was sewn in the same way, and the noncoronary sinus after that. Examination of the coaptation zone then necessitated plication of the left coronary leaflet in the center. The coronary arteries were reimplanted.

A 30-mm decellularized pulmonary homograft was then prepared for reconstruction of the right ventricular outflow tract (RVOT). The distal suture line was constructed with continuous 5-0 Prolene, and the proximal end of the homograft was then attached to the open RVOT with continuous 4-0 Prolene. Finally, the distal aortic anastomosis was performed. The cross-clamp was removed after a total ischemic time of 150 minutes, and the patient separated from cardiopulmonary bypass easily. Echocardiography showed excellent biventricular function with only trace central AI. After an uneventful ICU stay, he was discharged on postoperative day five.

While technically demanding, this case highlights the feasibility of autograft VSRR as an alternative to aortic root replacement for Ross patients with autograft failure. Reports of autograft VSRR demonstrate low operative mortality, often with rates lower than that of the index Ross procedure (3). Growing experience with VSRR will likely translate into a greater number of surgeons choosing to salvage the autograft valve, even in the presence of concomitant valvular disease requiring replacement or reconstruction.

References

1. Mazine A, El-Hamamsy I, Verma S, Peterso,n MD, Bonow RO, Yacoub MH, et al. Ross procedure in adults for cardiologists and cardiac surgeons: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72:2761-2777.
2. Buratto E, Wallace FRO, Fricke TA, Brink J, d’Udekem Y, Brizard CP, et al. Ross procedures in children with previous aortic valve surgery. J Am Coll Cardiol. 2020;76:1564-1573.
3. Mookhoek A, de Kerchove L, El Khoury G, Weimar T, Luciani GB, Mazzucco A, et al. European multicenter experience with valve-sparing reoperations after the Ross procedure. J Thorac Cardiovasc Surg. 2015;150:1132-1137.

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