Fourth Sternotomy With Ross/Konno After Previous Mechanical Aortic Valve Replacement: The Modified Root Inclusion Technique

The authors previously demonstrated the feasibility of the Ross procedure following a bioprosthetic aortic valve replacement (1). In this case, they showed its feasibility after a previous mechanical valve replacement. 

An 11-year-old boy, born with congenital aortic stenosis, underwent three previous sternotomies. The first two were for aortic valvotomy and valve repair, and the third was for mechanical aortic valve replacement at the age of four. He received a 16 mm mechanical prosthesis at that time.  

Follow-up evaluations indicated an increased gradient across the prosthesis, which was attributed to either pannus formation or patient-prosthesis mismatch. Fluoroscopy showed a stuck leaflet and restricted mobility of the second leaflet. A decision was made to proceed with a fourth sternotomy to explant the prosthesis and either perform the Ross procedure or replace it with another mechanical valve. The f 
ourth sternotomy was performed, and the pulmonary valve was evaluated and deemed suitable for the Ross procedure. 

Due to the pulmonary/left ventricular outflow tract (LVOT) annular size mismatch, a combination of mini-Konno and Manouguian annular enlargement was performed to accommodate the autograft into the LVOT. The coronary arteries were harvested in a way that preserved as much of the native aortic wall as possible, which was used to reinforce the autograft. A 25 mm cryopreserved pulmonary homograft was used to reconstruct the right ventricular outflow tract.  

Once the aortic reconstruction was completed and the patient was weaned off cardiopulmonary bypass, the pericardial patch used for the Manouguian posterior enlargement was wrapped around the autograft and sutured to the native aortic wall, thus the autograft was completely reinforced and supported.  
The postoperative course was uneventful, and the patient continued to do well during his follow-up, with competent autograft and homograft valves and excellent biventricular function.  Both the right and left ventricular outflow tracts remained widely patent, and the patient was free of anticoagulation (2). 

Please note that the coronary portion of this case was adopted from another case of the authors’ (non-redo) to show the coronary implantation in a better way to the viewer, due to malfunction in the camera recording at the time of the procedure. 

References

1. Said SM, Marey G. Fourth Sternotomy with Reinforced Ross Procedure. CTSNET. Tuesday, March 22, 2022. doi:10.25373/ctsnet.19398464
2. Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet. 1967 Nov 4;2(7523):956-958

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