Pioneering Precision: The Ross Procedure Unveiled

This video presents the case of a Ross procedure performed on a seven-year-old girl who presented with dyspnea upon exertion. The patient had been diagnosed at the age of six months to with congenital aortic stenosis. She had previously undergone a balloon aortic valvotomy at the age of six months but was discovered to have developed restenosis and severe regurgitation with a dilated aortic root. During the preoperative evaluation via echocardiogram, special attention was given to the pulmonary valve annulus size and the RV outflow. 

To begin the procedure, a standard median sternotomy was performed and the thymus was dissected. Ascending aortic cannulation and bicaval cannulation was performed to commence with cardiopulmonary bypass. A right superior pulmonary vein vent was also placed to prevent the left ventricle from becoming dilated. Ventricular fibrillation can be induced with the fibrillator if present or, as shown in the video, with a topical ice slush. 

After applying the cross clamp, cold blood cardioplegia was given directly through the coronary ostia. The aorta was transected and the aortic valve was examined. The crux of this operation, just like any operation of the aortic root, was meticulous coronary button harvesting. The thickened, diseased aortic leaflets were not amenable to repair. Next, the aortic valve leaflets were excised and the aortic annulus sized. 

Once the coronary buttons were harvested, attention was turned to harvesting the pulmonary autograft. A right angle was used to identify a point on the RV free wall just below the nadir of the pulmonary valve and an incision was made. Visual inspection of the pulmonary valve was mandatory to confirm its suitability into the aortic position and care was be taken to stay as far away from the coronary artery as possible. While dissecting the posterior wall, the team also had to be careful of the septal branch of the left anterior descending artery. The plane of posterior dissection can usually be found by the change in the direction of the muscle fibers. 

After harvesting the autograft, surgeons examined the pulmonary valve and took up the marking stitches. The autograft was then sutured to the aortic annulus with the running propylene sutures. Using a foreign material as a buttress is not advised, as it will hamper the growth. After this, the coronary button was stitched to the autograft. This suturing was performed with Prolene in a running fashion. The left coronary button was sutured first, followed by the right coronary. The dilated and the diseased part of ascending aorta was then excised. If required, a part of the autograph can also be excised for better orientation. 

Next, the proximal aortic suturing was performed again with Prolene suture in a running fashion. If required at this point, the anastomosis and the coronary buttons can be checked by giving cardioplegia through the aortic root of the neoaorta. While cardioplegia was going, surgeons were able to see the cardioplegia being flushed out of the thebesian veins that had opened at the autograft harvest site. These can be sutured if required. 

A homograft of adequate size was then sutured to both the proximal and distal part of the RVOT. In this case, surgeons used a commercially available 19 mm pulmonary homograft. Both the anastomoses were continuous stitches with Prolene. Once all the anastomoses were completed, the aortic cross clamp was removed. Surgical hemostasis was achieved, and the patient was weaned off cardiopulmonary bypass in the very first attempt in sinus rhythm. 

The postoperative transesophageal echocardiogram showed trivial aortic regurgitation and a good functioning autograft. The homograft in the pulmonary position was also adequately functioning. 

References

1. Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet. 1967;2(7523):956-958. doi:10.1016/s0140-6736(67)92667-x
2. El-Hamamsy I, Eryigit Z, Stevens LM, Sarang Z, George R, Clark L. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet. 2010;376(9740):524-531. doi:10.1016/S0140-6736(10)60610-7
3. Alsoufi B, Manlhiot C, McCrindle BW, Al-Halees Z, Sallehuddin A, Al-Ahmadi M. Results of Aortic Valve Replacement with Homografts in Children Ann Thorac Surg. 2011;92(3):931-937. doi:10.1016/j.athoracsur.2011.03.132
4. Stulak JM, Burkhart HM, Sundt TM 3rd, et al. Spectrum and outcome of reoperations after the Ross procedure. Circulation. 2010;122(11 Suppl):S81-S89. doi:10.1161/CIRCULATIONAHA.109.926070
5. Mookhoek A, Korteland NM, Arabkhani B, et al. The Ross procedure using autologous support of the pulmonary autograft: techniques and late results. Eur J Cardiothorac Surg. 2015;48(6):907-912. doi:10.1093/ejcts/ezu524

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