Ross Procedure With Internal and External Reduction Annuloplasty Using Autologous Tissue Rings

This video presents a Ross procedure with internal and external reduction annuloplasty using autologous tissue rings.

The patient was a 41-year-old previously healthy male who presented after a syncopal episode. Workup showed complete heart block, a bicuspid aortic valve with leaflet thickening, and a large vegetation on the non-coronary cusp, and 4+ aortic insufficiency (AI). Notably, his sinuses of Valsalva were dilated to 4.4 cm, and his annulus was 31 mm Due to his young age and endocarditis, an autograft (Ross procedure) was preferred. .

Annular dilation has previously been described as a relative contraindication to a Ross procedure; however, a novel strategy for reduction annuloplasty and proximal autograft and annular support using only autologous tissue was presented in this young patient with subacute endocarditis and a dilated annulus.

The operation began with a standard median sternotomy, aortic cannulation, and bicaval venous cannulation. Due to the degree of AI, the heart was arrested with both antegrade and direct retrograde Buckberg cardioplegia administered directly into the coronary sinus via a right atriotomy, which was visible during the procedure. Retrograde cardioplegia was given every 15 minutes, and direct ostial cardioplegia was administered every 60 minutes.

An aortotomy was performed, revealing a bicuspid aortic valve with thickened leaflets and fibrosis, suggestive of infectious vegetations in various stages of healing. The leaflets were excised, and the annulus was thoroughly debrided of all remaining biofilm.

Coronary buttons were prepared with careful attention to preserve wings of aortic tissue above and between the coronaries, which would be used later for autograft support in a semi-inclusion technique.

Given the patient’s dilated annulus in the setting of endocarditis, a reduction annuloplasty was planned using autologous tissue, buttressed both internally and externally. Two rings of aortic tissue, each 1 cm in thickness, were excised from the ascending aorta.

All excess adventitia was removed from the exterior surfaces of the rings. One ring was sewn internally and sub-annually using non-pledgeted mattress stitches passed through the internal ring and then the aortic annulus. Any pledgets needed were made using a strip of aortic tissue. The same sutures were passed through the external ring, taking wider bites to allow for downsizing to accommodate the neo-aortic valve.

The external ring was cut open to allow for wrapping around the entire root external to the annulus. An extra piece of aorta was added to complete the ring around the external aortic annulus.

Sutures were tied over a 24 mm Hagar dilator to size the annulus based on the patient’s body surface area. The downsizing also allowed for accommodation of the neo-aortic valve due to the smaller measured size of the pulmonic valve. A valve sizer was used to mark the nadirs of the sinuses to help orient the autograft.

Excision of the pulmonic valve is not shown due to time limitations, but it was inspected and excised using standard Ross techniques after being deemed appropriate for positioning as the neo-aortic valve. The excised pulmonic valve was anastomosed to the downsized aortic annulus using running polypropylene suture. Coronary buttons were appropriately positioned and anastomosed to the autograft using running polypropylene suture. The autograft was supported with native aortic tissue using the semi-inclusion technique, which the authors have published previously. This technique supported the root by wrapping it with the native aortic wings preserved from button harvesting, using running polypropylene suture. This extra support for the autograft root is thought to decrease risk of root dilation and therefore increase the longevity of a Ross procedure.

After this, a pulmonic valve homograft of appropriate size was chosen and anastomosed to the pulmonic valve annulus and pulmonary trunk in the usual fashion. Again, due to time limitations, this portion of the procedure was excluded from this case video.

The wrapped autograft was then anastomosed to a short Dacron interposition graft to stabilize the sinotubular junction. The Dacron graft was then anastomosed to the native ascending aorta.

After weaning from cardiopulmonary bypass, the neo-aortic valve showed excellent function on transesophageal echocardiography without any insufficiency. Hemostasis was achieved, and the chest was closed in the usual fashion (Figure 1).

Conclusions

In patients with a dilated annulus in whom a Ross procedure is preferred, the use of native aortic tissue may allow for successful annular downsizing while limiting the introduction of prosthetic material.

Figure 1

This image shows an intraoperative postoperative tracheoesophageal echocardiogram demonstrating an aortic valve leaflet coaptation length of 0.847 cm.

References

1. Frankel WC, Robinson JA, Roselli EE, et al. Lifetime Management of Adolescents and Young Adults with Congenital Aortic Valve Disease. The Annals of Thoracic Surgery. 2025;119(1):59-69. doi:10.1016/j.athoracsur.2024.04.038
2. Ryan WH, Squiers JJ, Harrington KB, et al. Long-term outcomes of the Ross procedure in adults. Ann Cardiothorac Surg. 2021;10(4):499-508. doi:10.21037/acs-2021-rp-fs-28
3. Glaser N, Persson M, Jackson V, Holzmann MJ, Franco-Cereceda A, Sartipy U. Loss in Life Expectancy After Surgical Aortic Valve Replacement. Journal of the American College of Cardiology. 2019;74(1):26-33. doi:10.1016/j.jacc.2019.04.053
4. Stelzer P, Mejia J, Varghese R. Operative risks of the Ross procedure. The Journal of Thoracic and Cardiovascular Surgery. 2021;161(3):905-915.e3. doi:10.1016/j.jtcvs.2020.11.161
5. Wenos CD, Herrmann JL, Timsina LR, Patel PM, Fehrenbacher JW, Brown JW. Perioperative and long‐term outcomes of Ross versus mechanical aortic valve replacement. Journal of Cardiac Surgery. 2022;37(10):2963-2971. doi:10.1111/jocs.16831
6. Ozturk M, Tongut A, Hanabergh SS, Yerebakan C, Khoury GE, d’Udekem Y. The Ross Procedure With the Inclusion Technique. Operative Techniques in Thoracic and Cardiovascular Surgery. 2022;27(4):414-422. doi:10.1053/j.optechstcvs.2022.06.012

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