Ross Procedure Using the Right Atrial Appendage Valve Instead of a Homograft: An All-Native Valve Approach

The Ross procedure has demonstrated excellent mid- and long-term outcomes (1), establishing it as the preferred aortic valve replacement for young patients in many centers. However, its primary limitation remains the reliance on a homograft in the pulmonary position, which frequently necessitates future reinterventions. This raises a critical question: Can a native tissue valve be used in the pulmonary position to delay or even eliminate the need for repeat procedures? 
 
Since 2018, the authors have employed the right atrial appendage (RAA) valve in both pulmonary and tricuspid positions. A step-by-step instructional video titled “How to Make a Valve for the RVOT from the Right Atrial Appendage”  is available on CTSNet, providing a step-by-step guide on RAA valve construction (2). Encouraged by promising mid-term results, the authors have refined their technique to integrate the RAA valve into Ross and Ross-Konno procedures. This video illustrates a modified approach for the Ross procedure in young and adult patients. 
In this 16-year-old patient, the surgeons harvested and prepared the RAA using the previously described technique for patients with tetralogy of Fallot. The surgeons modified the technique by constructing the RAA valve inside a Gore-Tex tube, creating a "T-RAA valve." This valved conduit functions similarly to a homograft and can be used in any scenario requiring a homograft in young or adult-sized patients, including Ross and Ross-Konno procedures or pulmonary atresia repair. 
 
Due to the fixed structure of the annulus and commissures, the surgeons do not anticipate changes in the valve’s geometry over time. Additionally, the living native tissue of the leaflets eliminates the long-term risks of degeneration or calcification. However, this technique can only be used when an adult-sized tube graft is appropriate, as the tube cannot dilate or grow. 
 
The 20 mm Gore-Tex tube used in this technique is the same as those employed in extracardiac total cavopulmonary connections (TCPC) patients for many years, with no signs of calcification or stenosis in long-term studies. Therefore, the authors expect this valved conduit to remain durable while preserving the option for future catheter-based valve reintervention if needed. 
 
Immediate and early echocardiographic studies confirmed excellent function of both the autograft and the T-RAA valve. 
 
For small children, where growth potential must be preserved, the surgeons avoided a fixed-size tube. Instead, they created a native posterior wall for the right ventricle-to-pulmonary artery (RV-to-PA) pathway using a piece of autologous ascending aorta—a technique that will be demonstrated in a separate video.  

References

1. Aboud, A., Charitos, E. I. Fujita, B., Stierle, U., Reil, J. C., Voth, V... & Ensminger, S. (2021). Long-term results of undergoing the Ross procedure. Journal of the American College of Cardiology, 77(11), 1412-1422.
2. Amirghofran AA. How to Make a Valve for the RVOT from the Right Atrial Appendage. Ctsnet.org. Published online October 19, 2022. doi:https://doi.org/10.25373/ctsnet.21354825.v1

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