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Reinforced Ross Procedure for a 44-Year-Old Woman with Acute Aortic Insufficiency Due to a Commissural Rupture

Tuesday, March 14, 2023

Paneitz DC, Cameron DE, Bloom JP. Reinforced Ross Procedure for a 44-Year-Old Woman with Acute Aortic Insufficiency Due to a Commissural Rupture. March 2023. doi:10.25373/ctsnet.22270327.v1



A 44-year-old female with no past medical history presented with acute onset chest pain and new heart failure. A workup revealed severe aortic insufficiency (AI) with a bicuspid aortic valve that appeared to be prolapsing. The patient was stabilized and deemed a suitable candidate for the Ross procedure (1,2).

After a median sternotomy, cardiopulmonary bypass was initiated via aorto-bicaval cannulation. Due to the severe AI, the heart was cooled topically and electrically fibrillated prior to cross-clamp. The ascending aorta was opened, and 1 liter of cold antegrade 4:1 blood cardioplegia was instilled into the coronary ostia.

The valve was a Sievers Type I bicuspid with left-right fusion. The raphe attached to the conjoined leaflet had ruptured from the commissure and there was a frank adjacent perforation. The leaflets were excised. Attention was then turned to the pulmonary valve (PV), and the main pulmonary artery (PA) was opened at the bifurcation of the right PA. The PV was normal, and the main PA was transected. The pulmonary autograft was excised from the right ventricle 4 mm proximal to the annulus using sharp dissection. Care was taken not to disrupt the first septal perforator.

Next, the coronary buttons were dissected and the root was skeletonized. 2-0 polyester sutures with pledgets were circumferentially placed around the aortic annulus using an everting technique. The PV was sized to 28 mm. To stabilize the ventriculoaortic junction, an external annuloplasty was fashioned using four graft divisions from a 34 mm Dacron graft. The sutures were then passed through the autograft and the annuloplasty ring and tied. The valve was examined without issue.

The coronary buttons were then sewn to the autograft using a 4 mm punch and 5-0 polypropylene suture. The autograft was trimmed to 1 mm beyond the sinotubular junction (STJ) and sized to 28 mm. A 28 mm synthetic graft was used to replace the ascending aorta and stabilize the STJ, resulting in a reinforced Ross. This also enabled valve competency testing, which was confirmed using cardioplegia delivery.

Next, a 30 mm decellularized human pulmonary homograft was used for the RVOT reconstruction. The muscular cuff and distal PA were trimmed. The distal PA anastomosis was completed followed by the distal ascending aortic anastomosis. Finally, the proximal homograft was sewn to the right ventricular outflow tract. The heart was de-aired and weaned from bypass, and the chest closed in standard fashion. Postoperative TEE showed no AI and trace PI. The patient was discharged home on day five with a repeat TTE showing no AR and no measurable gradients.

In conclusion, the Ross procedure may be considered for young patients with aortic valve pathology.


  1. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. 1967 Nov 4;2(7523):956-8. doi: 10.1016/s0140-6736(67)90794-5. PMID: 4167516.
  2. Mazine A, El-Hamamsy I, Verma S, Peterson MD, Bonow RO, Yacoub MH, David TE, Bhatt DL. Ross Procedure in Adults for Cardiologists and Cardiac Surgeons: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018 Dec 4;72(22):2761-2777. doi: 10.1016/j.jacc.2018.08.2200. PMID: 30497563.


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