Technique for Preserving Neo-Aortic Root Diameters and Valve Geometry in the Ross Operation

Patient Selection 

Every patient with aortic valve disease (stenosis, insufficiency, or a combination of both) who is eligible for a Ross procedure can be considered. In children, the size of the pulmonary root must be adequate for an adult-size valve.  

Operative Steps 

Harvesting of the Pulmonary Autograft 

The pulmonary artery was transected at the pulmonary bifurcation. The pulmonary valve was inspected to determine its eligibility for the Ross procedure. The pulmonary root was dissected down to the muscular infundibulum. During this process, attention was given to the left main coronary artery, the first septal perforator, and the right coronary artery. Using a right-angled clamp, the correct position was marked approximately 5 mm below the pulmonary valve in the right ventricular outflow tract (RVOT), and the infundibulium was incised. The autograft was excised along the muscular ring. 

Preparation and Reinforcement of the Pulmonary Autograft 

The prosthesis was divided into four quadrants, which were marked with lines. The proximal ring of the pulmonary autograft was also divided into four sections and marked with 5-0 monofilament nonabsorbable suture. The autograft was circumferentially sutured to the prosthesis with four continuous suture lines. This method facilitated the preservation of the valve’s geometry. The length of the prosthesis was adapted to the length of the pulmonary autograft. This was done in all four quadrants by stretching the prosthesis and the autograft during the placement of the sutures, ensuring that the natural course of the pulmonary root, which is slightly curved, was maintained. The distal circumference was then sutured to the prosthesis with four continuous sutures lines. In this way, personalized external support of the autograft was provided. 

Excision of the Aortic Root and Mobilization of the Coronary Arteries 

The aorta was cross-clamped. The ascending aorta was transected, and cardioplegic solution was administered selectively via the coronary ostia. The coronary buttons were excised and mobilized. The aortic root was completely removed. 

Proximal Anastomosis Between the Left Ventricular Outflow Tract and Pulmonary Autograft 

The autograft was oriented with the sinus at the shortest side toward the left coronary artery. The proximal anastomosis was performed using 4-0 monofilament nonabsorbable continuous sutures. 

Reimplantation of the Left Coronary Button 

A piece of prosthesis and the autograft were excised, and the anastomosis between the left coronary button and the pulmonary autograft was made with a 5-0 monofilament nonabsorbable suture. It is important to avoid placing stiches into the prosthesis to prevent hematoma inclusion between the autograft root and the prosthesis. The commissure between the right and noncoronary sinus was marked. 

Distal Anastomosis Between Pulmonary Autograft and Ascending Aorta 

The ascending aorta was trimmed to avoid kinking after the cross-clamp was opened. The next step was the distal anastomosis of the autograft root and the ascending aorta, performed using a 4-0 monofilament nonabsorbable suture. The reconstruction was filled with cardioplegic solution to determine the correct position of the right coronary anastomosis. 

Reimplantation of the Right Coronary Button 

Finally, the right coronary anastomosis was completed with a 5-0 monofilament nonabsorbable suture. The left heart was deaired, and the cross-clamp was opened. 

RVOT Reconstruction 

Bleeding of small vessels of the RVOT was controlled, and a cryopreserved pulmonary homograft was shaped and used for the RVOT reconstruction. For this last step, continuous 4-0 monofilament nonabsorbable sutures were used to complete the distal and proximal anastomosis. 

Tips and Pitfalls 

During the preparation process, the surgeon should stay next to the aorta and not too close to the pulmonary root to prevent damaging the autograft, as the aorta is excised anyway. If the patient has a patent foramen ovale (PFO), double venous cannulation is used for cardiac bypass, and the PFO is closed prior to harvesting the pulmonary autograft. 

Harvesting and reinforcement of the autograft are performed on a beating heart to minimize ischemic time, as the reinforcement takes about 45 minutes. After harvesting, excessive fat tissue is removed from the autograft with caution, ensuring that the adventitia remains intact. The pulmonary root is sized with caution, as it can easily be distended, and an appropriate Dacron prosthesis with and additional diameter of 2 mm is used for autograft reinforcement. 

The autograft is oriented with the sinus at the shortest side toward the left coronary artery to imitate the natural curve of the aortic root. When the coronary buttons are implanted into the autograft, the prosthesis must not be stitched to prevent the possibility of hematoma inclusion around the autograft. The distal anastomosis of the RVPA conduit should be carefully executed.  

References

1. Ratschiller T, Sames-Dolzer E, Schimetta W, Kreuzer M, Müller H, Zierer A, Mair R. External Prosthetic Reinforcement of the Pulmonary Autograft. Thorac Cardiovasc Surg. 2019 Jan;67(1):14-20.
2. Ratschiller T, Eva SD, Schimetta W, Paulus P, Müller H, Zierer A, Mair R. Valve-sparing root replacement for freestanding pulmonary autograft aneurysm after the Ross procedure. J Thorac Cardiovasc Surg. 2018 Jun;155(6):2390-2397.
3. Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Dávila-Román VG. The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg 2004; 78 (03) 773-781 , discussion 773–781
4. Pasquali SK, Cohen MS, Shera D, Wernovsky G, Spray TL, Marino BS. The relationship between neo-aortic root dilation, insufficiency, and reintervention following the Ross procedure in infants, children, and young adults. J Am Coll Cardiol 2007; 49 (17) 1806-1812

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