Inclusion Ross Procedure With Hemiarch Repair Using Antegrade Cerebral Perfusion: The Modified Starnes Technique

Owing to its excellent hemodynamic properties without necessity of anticoagulation treatment, the Ross procedure is an attractive option for nonelderly adults with aortic valve pathology. Although this is a well-established procedure in experienced hands, autograft dilatation had remained a concern, requiring reoperation, including valve replacement. In 2001, Starnes and colleagues adopted the pulmonary autograft inclusion technique (the wrapped Ross technique), in which the pulmonary autograft is reinforced within a woven Dacron conduit, sized to the aortic annulus and pulmonary autograft. The rationale is to provide external support for the pulmonary autograft, stabilize the aortic root, and prevent progressive dilatation and autograft failure over time.  

Case and Surgical Techniques 

The patient was a quadragenarian who presented with shortness of breath. Echocardiography showed a bicuspid aortic valve with severe aortic insufficiency, a mean gradient of 10 mmHg, and an LVEF of 45 percent. CTA showed an ascending aneurysm and aortic root aneurysm (5 cm). An inclusion Ross procedure and hemiarch replacement were planned. 

A median sternotomy was performed, and the right axillary artery was directly cannulated. For venous drainage, the bi-caval technique was utilized. The aorta was cross-clamped, and Del Nido cardioplegia was administered in a retrograde and selective fashion. A left ventricular vent was inserted through the right upper pulmonary vein. With the heart arrested, the aortopulmonary window was completely separated. The aorta was divided just above the sinotubular junction. Since the aortic valve was deemed unrepairable, in line with the preoperative gradient, the leaflets were excised, and the annulus was debrided. Coronary buttons were prepared in the usual fashion, similar to the Bentall procedure. 

The separation of the pulmonary valve from the right ventricular outflow tract began with an incision in the infundibular area, 1.5 cm below the pulmonary valve. The incisional plane was above the first septal perforator off the left anterior descending artery. Hemostasis of venous plexuses posterior to the pulmonary valve was achieved using antegrade or retrograde cardioplegia. A 3 to 4 mm rim of musculature was preserved on the pulmonary autograft to facilitate the creation of the wrapped autograft and implantation into the left ventricular outflow tract. Care was taken to maintain the same distance from the pulmonic valve throughout to ensure that it was symmetrical circumferentially.  

Once the autograft was excised, the annulus of the pulmonary autograft was measured using a Hegar dilator to choose a Dacron graft 3 to 4 mm larger than the pulmonary autograft. In this case, a 30 mm Dacron graft with the sinus of Valsalva was used, based on the size of the pulmonic autograft (26 mm). The autograft was then attached to the Dacron graft at the annular level with three pairs of running 5–0 polypropylene sutures, with each suture starting from the commissure and tied at the nadir of the valve. This facilitated hemostasis and ensured symmetrical implantation during the proximal anastomosis (Dr. Starnes used a mattress suture to secure this muscle skirt). At the distal end of the autograft, three 5-0 buttress stitches were placed at each of the commissures to make it symmetrical. A separate running 4-0 polypropylene suture was used to secure the distal end above the commissure level (Dr. Starnes used a single-running suture). The surgeons then anastomosed this composite autograft to the aortic annulus with 3-0 polypropylene sutures taken through the graft and muscle skirt, completing the left ventricular outflow tract reconstruction. Three pairs of 3-0 stitches were used starting from the right and left commissure (Dr. Starnes used a single-running polypropylene suture). In case of displacement of the left coronary button, the orientation of the composite autograft needs to be adjusted, as learned from Dr. Starnes. For example, if the left coronary button rotate was malrotated to the left and noncommissure, the composite autograft could be rotated counterclockwise to accommodate the location of the left coronary button. The valve was then tested for competence. 

Reimplantation of the coronary buttons in both the autograft and the Dacron graft was performed using a 5-0 polypropylene suture (BV-1 needle). An 11-blade was used from the inside of the composite autograft to create a hole in both the autograft and Dacron graft. Creating a larger hole in the Dacron graft rather than the autograft facilitates anastomosis as an autograft easily stretches. 

It was important to incorporate the autograft tissue, a Dacron graft, and the native coronary button. The surgeons did not use a felt strip on the coronary button. In patients who need hemiarch repair, the ascending graft is extended using a piece of Dacron graft, which secures the distal end of the composite autograft. In addition, antegrade cardioplegia can be given to check the competency of the autograft and hemostasis of suture lines.  

A 31 mm pulmonary homograft was brought into the field, and the distal end was anastomosed using 4-0 polypropylene suture. Then the bottom-half of the proximal anastomosis was performed. Care should be taken not to take a deep bite in the back wall to avoid catching the first septal branch.  

At a bladder temperature of 28 degrees Celsius, circulatory arrest of the lower body was initiated with unilateral antegrade cerebral perfusion via the right axillary artery. Both the innominate artery and left carotid artery were clamped using small clamps. During nine minutes of lower body circulatory arrest, the proximal aortic arch was resected, and the distal aortic anastomosis was performed using running 4-0 polypropylene sutures. De-airing was performed, and systemic perfusion was restored, marking the end of myocardial ischemic time. Cross-clamp time was 160 minutes in this case. The remaining proximal homograft anastomosis was completed while the heart was being perfused. After rewarming was completed, the patient was weaned from cardiopulmonary bypass without any difficulty. Cardiopulmonary bypass time was 220 minutes. Postoperative echocardiography showed trace aortic insufficiency. The patient was discharged home and is doing well. 

References

1. Starnes VA, Elsayed RS, Cohen RG, Olds AP, Bojko MM, Mack WJ, Cutri RM, Baertsch HC, Baker CJ, Kumar SR, Bowdish ME. Long-term outcomes with the pulmonary autograft inclusion technique in adults with bicuspid aortic valves undergoing the Ross procedure. J Thorac Cardiovasc Surg. 2023 Jan;165(1):43-52.e2.
2. El-Hamamsy I., Eryigit Z., Stevens L.M., Sarang Z., George R., Clark L., et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet. 2010;376:524–531. doi: 10.1016/S0140-6736(10)60828-8.
3. Starnes VA, Bowdish ME, Cohen RG, Baker CJ, Elsayed RS. The Ross procedure utilizing the pulmonary autograft inclusion technique in adults. JTCVS Tech. 2021 May 31;10:372-376.

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