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Ross Procedure After Previous Aortic Valve Repair in an Adult

Wednesday, November 25, 2020

Marey G, Said S. Ross Procedure After Previous Aortic Valve Repair in an Adult. November 2020. doi:10.25373/ctsnet.13262564

The authors present a repeat median sternotomy with a Ross procedure after previous aortic valve (AV) repair. This was a 31-year-old man with a BMI of 29 kg/m2 who presented with exertional dyspnea and fatigue. His past medical/surgical history was significant for congenital bicuspid AV stenosis for which he underwent balloon aortic valvuloplasty at 10 years of age, followed by aortic valve repair at age 14. Echocardiography showed bicuspid AV mixed moderate-to-severe stenosis and regurgitation, and he had mild left ventricular enlargement with normal systolic function. The mean gradient across the AV was 30 mm Hg. Catheter pullback across the AV revealed a gradient of 64 mm Hg.

After repeat median sternotomy, cardiopulmonary bypass (CPB) was initiated via central aortic and bicaval cannulation. Aortic cross clamp was applied and antegrade cardioplegia was administered. The pulmonary autograft was harvested using electrocautery and trimmed. The aortic root was prepared and coronary buttons were harvested. The autograft was implanted using running 5/0 prolene suture supported with bovine pericardial strips, followed by reimplantation of the coronary buttons in the corresponding sinuses of Valsalva of the neo-aortic root. The authors kept the native noncoronary sinus in place as they believe it provides a hemostatic layer and support for the autograft in this area. To stabilize the neo-sinotubular junction, they replaced a portion of the ascending aorta using a 24 mm hemashield graft.

A decellularized 30 mm pulmonary homograft was used to restore the right ventricular to pulmonary arterial confluence continuity. This was followed by reconstruction of the distal graft to native aortic anastomosis. The heart was then de-aired and the cross clamp was removed. The patient regained his normal sinus rhythm and was weaned off CPB without difficulty. The aortic cross clamp time was 127 minutes, and the cardiopulmonary bypass time was 166 minutes. The patient was extubated a few hours after surgery, received no transfusions, and remained in normal sinus rhythm.

The rest of his hospital course was uneventful and he was discharged home on the sixth postoperative day. Pre-dismissal transthoracic echocardiography showed unobstructed flow across the left ventricular outflow tract with no neo-aortic valve regurgitation or stenosis. The peak gradient across the neo-aortic valve was 4 mm Hg, and it was 17 mm Hg across the pulmonary homograft, and the ventricular function remained normal.

Finally, the Ross procedure remains the best procedure for young patients with active lifestyles due to the excellent hemodynamics, lack of anticoagulation, and absence of patient-prosthesis mismatch.


  1. Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet. 1967 Nov 4;2(7523):956-958.
  2. El-Hamamsy I, Eryigit Z, Stevens LM, 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 Aug 14;376(9740):524-531.
  3. David TE, Ouzounian M, David CM, Lafreniere-Roula M, Manlhiot C. Late results of the Ross procedure. J Thorac Cardiovasc Surg. 2019 Jan;157(1):201-208.


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Thank you for sharing the video. On 0:43 you are reporting on Bicuspid Aortic Valve. The Valve is TRI-leaflet clearly. There are still surgeons who will harvest the autograft with use of scissors and not electrocautery. It is 'easier' to harvest the autograft with scissors as one can identify easier the 2 anatomic layers on the septum (the 1st septal perforator is posterior to the 2nd layer). We incise the inner layer perpendicular and the outer obliquely. Additionally, is easier to harvest autograft after the coronary buttons have been disconnected from the aortic root. One has a better visualisation of LCA main stem if the aortic root is completely taken down. 3mm discrepancy between native aortic root and pulmonary root, can be easily matched, even without the anterior augmentation of the aortic annulus. I understand that you might me doing the anterior augmentation so you can guaranty an intra-annular insertion of the autograft. Continuous suture line can lead to purse-sting phenomena, and one can easily 'loose' a few mm of circumference due to the purse-string effect. Semi-continuous with 3 monofilament sutures can be an option if one choses not to use interrupted. You are right on that the neo-aortic root can dilate on the area of the non-coronary sinus. Traditionally the anterior Pulmonary sinus, is used for that point (ie rotated implantation of the autograft). What I just mention, is not possibly only if you do a true Ross-Konno, and the Anterior Pulmonary sinus with the RVOT muscular 'skirt' is implanted exactly on the IVS. What was the original diameter of the ascending aorta? Did you replace the ascending aorta only so you can prevent future STJ dilatation?! Why to have a gradient of 17mmHg on the Pulmonary Homograft? Thank you for sharing your work and allowing for comments/discussion. Another video with referrals to the Ross procedure:
Thank you for your comment. Here are the responses to your questions: 1. The patient was born with a bicuspid aortic valve. He underwent an initial balloon valvuloplasty followed by repair through a creation of a pericardial leaflet to change in to what you saw on Echo as if it is a tri-leaflet valve but it is originally bicuspid. I did not go into these details due to the length of the video. 2. While you can use either technique to harvest the autograft, I find the electrocautery superior and at higher degree of accuracy and precision than the scissors. It is a matter of what you are comfortable with and what you are used to so as long you do not damage the autograft 3. You can harvest the autograft at any stage, again this depends on what you are comfortable with. 4. I try as much as I can to support the autograft in the aortic root/LVOT especially in adults due to obvious drawbacks of just placing it on top of the LVOT despite it is easier. I also wrapped in some adult patients inside a Hemashield graft for the same concerns 5. While it is a theoretical concern with any running suture, I never seen it and I doubt if it occurs if you place you sutures correctly. Also you can always tie on a Hegar if you worried about. I have used the interrupted technique early on but I do not like it due to the time it takes. 6. I have a low threshold to replace a small portion of the ascending aorta to stabilize the ST junction and if not I will wrap it with a sleeve of Dacron for the same reason 7. I do not believe the Echo gradient on these large size homografts, there was no RVOT at any levels Ross has been modified millions of times and I don't see any difference in any of the techniques described so as long the basic rules are followed: meticulous harvest of the autograft, trimming the autograft to minimum, supporting the autograft with native LVOT and aortic tissue, stabilization of ST junction and using the largest possible homograft. Anything else is a surgeon's preference otherwise no technique is better than another one.

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