The Ross Procedure Unveiled: Insights into Various Techniques and Modifications

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The authors present an instructional video demonstrating the techniques and modifications for autograft and right ventricular outflow tract (RVOT) reconstruction in the Ross procedure, using eight different examples from eight different patients. 
 
1. Autograft: Autograft Harvest on Arrested Heart 
 
This is the standard technique used by many, allowing for the evaluation of the native aortic valve to determine if repair is an option. This method may also be more comfortable due to the reduced risk of injury to the first septal perforator and the autograft valve.  
 
However, this technique will have a longer ischemic time. 
 
2. Autograft: Beating-Heart Harvest and Autograft Reinforcement 
 
Harvesting the autograft on a beating heart minimized ischemic time, while reinforcement with full Dacron prevents future dilation. The autograft was implanted inside a Dacron graft and secured proximally with three sutures, using the markings of the graft to facilitate orientation of the autograft. The graft was then everted to facilitate testing of the valve, allowing avoidance of an extra suture line when replacement of the ascending aorta was necessary. The distal anastomosis of the autograft to the Dacron graft was completed with three additional sutures. The reinforced autograft could also be implanted as a full root Bentall. This technique may also allow for the expansion of the Ross procedure to other patients, especially those with connective tissue disorders. 
 
It is important to ensure that the aortic valve is nonrepairable, which requires experience to avoid risk of injury to the autograft valve’s first septal perforator. 
 
3. Autograft: Ross in the Setting of a Dilated Left Ventricular Outflow Tract 
 
In the setting of a dilated left ventricular outflow tract (LVOT), a strip of Dacron is used as an annuloplasty to decrease the LVOT diameter. However, this is not completely necessary if full Dacron support is used to reinforce the autograft. This case also demonstrates the simple interrupted suture technique for the implantation of the autograft. 
 
4. Autograft: Ross-Konno 
 
Ross-Konno is indicated when there is significant autograft to LVOT size mismatch and is commonly used for those with congenital severe aortic stenosis and a hypoplastic aortic annulus. It is important for the surgeon to be aware of the conduction tissue location to avoid heart block with the Konno incision. This can be accomplished by directing the Konno incision horizontally or in an oblique fashion. A mini-Konno incision combined with septal myectomy is often sufficient to reimplant the autograft in many situations. The combination of mini-Konno with small posterior annular enlargement (Manaugian) can be used to manage the significant autograft to LVOT size mismatch. 
 
5. Autograft: Ross Procedure in Challenging Settings—Fourth Sternotomy 
 
The Ross procedure can also be applied in reoperative settings. Performing maximal dissection with electrocautery at low settings prior to heparinization minimizes post-bypass bleeding. It is also important to always think about the phrenic nerve in these settings, as the location of the phrenic nerve can change with prior operations and may lie closer than one might think. When harvesting the autograft, one should be careful when close to the lateral wall of the autograft, where the left main and the left anterior descending coronary arteries can be close and difficult to visualize with multiple reoperations. In reoperations, the tissues are usually quite strong when securing the reinforced autograft to the LVOT, so hemostasis should not be an issue. 
 
6. RVOT Reconstruction: Freestyle Xenograft 
 
Using a freestyle xenograft for reconstruction of the RVOT has excellent long-term outcomes while having the advantage of being readily available. The xenograft may be a bit short and stiff relative to the RVOT muscle and pulmonary artery branches; therefore, using a Dacron extension may avoid any tension. 
 
However, the cost may be a hinderance in some areas, though it is less than a homograft. 
 
7. RVOT Reconstruction: Hand-Made Valved Conduit 
 
Reconstructing the RVOT using a hand-made valved conduit has good long-term outcomes and is widely available. Transcatheter valve-in-valve interventions are also feasible with this technique. 
 
However, long-term outcomes are less than those of homografts and may be costly, albeit more cost-effective relative to homografts and xenografts. 
 
8. RVOT Reconstruction: Autologous Pericardium 
 
The RVOT can be reconstructed using autologous pericardium, which, in combination with the autograft, provides a total autologous reconstruction of both the RVOT and LVOT. This technique is extremely cost-effective and provides excellent hemodynamics. 
 
Operative time may be longer, though, and data is still needed to evaluate long-term outcomes. 

References

1. Marey G, Said S. Ross Procedure After Previous Aortic Valve Repair in an Adult. November 2020. doi:10.25373/ctsnet.13262564
2. Said SM. Reinforced Ross Procedure in an Adult "Beating Heart Autograft Harvest". October 2021. doi:10.25373/ctsnet.16746007
3. Mazine A, El-Hamamsy I. The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques. Ann Cardiothorac Surg. 2021 Jul;10(4):463-475. doi: 10.21037/acs-2021-rp-25. PMID: 34422558; PMCID: PMC8339621.
4. Said SM. The Ross-Konno procedure for congenital aortic stenosis. Ann Cardiothorac Surg. 2021 Jul;10(4):527-537. doi: 10.21037/acs-2021-rp-31. PMID: 34422569; PMCID: PMC8339636.
5. Said SM, Marey G. Fourth Sternotomy with Reinforced Ross Procedure. March 2022. doi:10.25373/ctsnet.19398464
6. Said SM, Mashadi AH, Gabr MA, Elderie A, Sanad M. Modified Ross procedure with four different strategies for right ventricular outflow tract reconstruction. Multimed Man Cardiothorac Surg. 2025 Apr 2;2025. doi: 10.1510/mmcts.2025.007. PMID: 40171624.
7. Said SM, Mashadi AH, Gabr MA, Alaaeldin F, Kamalou M, Elhadidi S, Abdelhameed MA, Badr-Eldin MN, Yousef R, Elderie A, Sanad M. Total autologous reconstruction of the right and left ventricular outflow tracts: the case for the modified Ross-Ozaki procedure. Multimed Man Cardiothorac Surg. 2025 Jan 24;2025. doi: 10.1510/mmcts.2024.129. PMID: 39853170.

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