Double-Inclusion Ross Technique for Patients With Aortopathy and Aorto-Pulmonary Mismatch

The authors present a video demonstrating the double-inclusion Ross technique in a 36-year-old patient with severe bicuspid aortic valve stenosis, aortopathy, and a significant mismatch between the aortic anulus/left ventricular outflow tract (LVOT) and the pulmonary autograft.

Considering the mismatch and aneurysmal aorta, downsizing of the annulus and LVOT was performed to create appropriate media for autograft implantation, along with graft reinforcement of the sinuses on top of the aortic inclusion.

Briefly, deep sub-annular aortic root dissection was performed, a step that the authors believed was of crucial importance in stabilizing the LVOT and in preventing LVOT pseudoaneurysm formation due to tension from significant downsizing. After graft parachuting, similar to valve-sparing root replacement, a minimum of 10 sub-annular pladgeted sutures were tied over an autograft-matched Hegar dilator to provide nonobstructive LVOT stabilization. The autograft was then implanted in the usual fashion, considering individual differences in the sinuses and leaflets.

The sinus portion of the prosthetic graft was loosely added on top of the native aortic tissue as a second layer of inclusion. This approach was intended to enable the autograft to expand while maintaining its native elasticity and characteristics, and at the same time, it might improve long-term durability by limiting future over-dilatation.

The authors believe that the double-inclusion Ross technique might be a useful short- and long-term solution for young patients with aortic valve pathology that is not amenable to repair, large aneurysms, and the aforementioned mismatch.

References

1. Mazine A, Ghoneim A, El-Hamamsy I. The Ross Procedure: How I Teach It. Ann Thorac Surg. 2018 May;105(5):1294-1298. doi: 10.1016/j.athoracsur.2018.01.048. Epub 2018 Feb 23. PMID: 29481789.
2. Svensson LG. The art of aortic valve repair. JTCVS Tech. 2021 Jan 28;7:121-125. doi: 10.1016/j.xjtc.2021.01.030. PMID: 34318222; PMCID: PMC8311601.

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