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This video demonstrates a Ross procedure with annular stabilization, an interposition graft, and a loose-jacket technique. The patient was a 52-year-old man with severe aortic regurgitation and a history of a bicuspid aortic valve diagnosed in childhood. He was classified as New York Heart Association class I, had no relevant medical or surgical history, took no medications, and presented only with a diastolic decrescendo murmur and a systolic ejection murmur on exam.
Preoperative echocardiography showed severe aortic regurgitation, normal ejection fraction, and borderline left ventricular dilation. There was no other hemodynamically significant valve disease. Computed tomography (CT) imaging demonstrated an annular diameter of 30 mm, a sinus of Valsalva diameter of 50 mm, a sinotubular junction diameter of 45 mm, and an ascending aorta of 44 mm tapering toward the aortic arch. Multiplanar CT reconstruction suggested a potential unicuspid aortic valve. Given these findings, durable valve repair was not considered feasible, and a Ross procedure was planned.
At the authors’ institution, this evaluation routinely includes cardiac magnetic resonance imaging (MRI) to assess pulmonic valve morphology, which revealed normal leaflet motion and normal annular dimensions. Intraoperative transesophageal echocardiography confirmed a unicuspid aortic valve with severe regurgitation. Inspection of the aortic valve reaffirmed the unicuspid morphology and supported the preoperative decision to proceed with a Ross procedure.
The annulus was sized with a 29 mm dilator. The aortic valve was excised, and the coronary buttons were mobilized in a rectangular fashion, leaving a 2–3 mm rim of aortic tissue. It is essential to dissect the aorta away from the coronary button—not the reverse. The left coronary button was extensively mobilized.
A deep dissection into the Ross plane was then performed. The right coronary button was prepared in a similar manner, but mobilization was kept to a minimum to avoid distortion or kinking during reimplantation.
Afterward, the aortic root dissection was carried deeper. Commissural symmetry was reassessed with sizers. If needed, the new commissural positions were marked to ensure a 120-degree distribution. To help with exposure, a suction catheter was positioned to the right of the pulmonary artery with downward counter traction. Using the right pulmonary artery as a landmark, the incision was made a few millimeters below it.
The pulmonary valve was examined, focusing on leaflet configuration, commissural alignment, and the presence of fenestrations. The incision point was marked 5 mm below the nadir using a right-angle instrument. Dissection proceeds 3–5 mm below the hinge point of the leaflets. During this portion of the dissection, care was taken to maintain an adequate distance from the right coronary artery. The pulmonary artery was mobilized away from the left coronary artery. Remaining 5 mm below the hinge point and keeping a horizontal dissection plane prevented injury to the first septal perforator.
The commissures and neo-sinuses were marked, and excess muscle was trimmed as required. The autograft was placed in a dry tin cup without saline. If the aortic annulus measured more than 28 mm, or if the size difference between the aortic and pulmonary annuli exceeded 3 mm, annular stabilization was performed. Six 2-0 braided sutures with mini-pledgets were placed—three at the nadirs and three below the commissures.
These sutures were passed through the graft, after which a 2–3 mm ring was fashioned and placed around the annulus. With a 27 mm dilator in place, the sutures were tied. Next, the homograft was prepared. In this case, a 30 mm homograft was used. It was trimmed below the bifurcation, the annular muscle was reduced, and orientation marks were placed on the lateral and anterior aspects.
The proximal anastomosis was completed with a continuous 4-0 Prolene suture. Care was taken to avoid deep bites along the posterior wall to prevent injury to the septal perforator.
The leaflets were inspected after completing the running suture. The distal anastomosis was sewn using a continuous 5-0 Prolene suture, with the anterior segment interlocked to avoid narrowing of the lumen. Throughout the Ross procedure, the surgeons alternated between antegrade and retrograde del Nido cardioplegia.
The autograft was positioned, and interrupted 4-0 sutures were placed. The surgeons began at the nadir of the right commissure and progressed toward the left. The goal was subannular implantation—anchoring the autograft inside the left ventricular outflow tract (LVOT). Deep bites were taken from the aortic annulus into the LVOT. For the pulmonary autograft, the needle entered at the annular level and exited slightly above the hinge point. No felt or pericardium was used for this step.
After placing all sutures, the autograft was parachuted down and secured. Leaflet motion and coaptation were reevaluated. A right-angle instrument was used to mark the midpoint between corresponding commissures. An incision was made, and the neo-ostia were created using 4.0 mm and 4.8 mm punches. Coronary buttons were reimplanted with a continuous 5-0 Prolene suture. To maintain anatomical orientation, the commissure for the interposition graft was marked. Autologous pericardium was used to reinforce this anastomosis, which was sewn with a continuous 4-0 Prolene suture. The distal anastomosis of the interposition graft was then completed. After placing an aortic root vent, meticulous deairing was performed.
Immediately after unclamping, the empty beating heart was assessed for aortic regurgitation. Residual aortic tissue was used to fashion a loose external jacket to avoid future dilatation. It was essential to keep the jacket loose; overtightening may distort autograft geometry and induce regurgitation. Loose 5-0 Prolene stitches were used to secure the jacket. The same loose-jacket principle was applied to the opposite side.
Final assessment was performed with transesophageal echocardiography. The patient was extubated on postoperative day zero, transferred out of the intensive care unit (ICU) on day one, and after an otherwise uneventful hospital course, discharged home on day five. Prior to discharge, a transthoracic echocardiogram (TTE) confirmed normal ejection fraction (EF) and good function of both the autograft and the homograft. Tight blood pressure control with a target systolic less than 110 mmHg was recommended for six months, along with nonsteroidal anti-inflammatory drug (NSAID) therapy.
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