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Valve-Sparing Aortic Root Replacement for Late Failure of the Ross Procedure
When autograft dilation and neo-aortic valve regurgitation develop late after the Ross procedure, there are two surgical options: aortic root replacement with mechanical or biological prosthesis, or aortic valve preservation (valve-sparing aortic root replacement (VSRR)).
This video shows an adolescent male who presented with aortic root enlargement and severe aortic regurgitation five years following a Ross procedure. The ascending aorta, densely adherent to the sternum, was lacerated on reentry. Bleeding was controlled by re-approximation of the sternal edges. Femoral cannulation was expeditiously accomplished, but given the severity of aortic valve regurgitation, the patient continued to eject on cardiopulmonary bypass. An apical left ventricular vent was inserted via a limited left anterior thoracotomy, and instituted rapid cooling. As soon as the heart fibrillated, the sternotomy was rapidly completed, and control of the distal ascending aorta was obtained within six minutes of circulatory arrest. The heart was arrested with an antegrade intra-coronary infusion of cold blood cardioplegia.
The neo-aortic valve appeared intact, and the aortic regurgitation was deemed as secondary to the splaying of the sinotubular junction. The authors thought that an aortic root replacement with a mechanical prosthesis was not ideal. Proceeding with a VSRR procedure was also thought ill-advised because of its inherent complexity, as the authors were hopeful that the myocardium had not been injured by left ventricular distension. It was decided to downsize the sinotubular junction in the hope that competency of the aortic valve would be restored.
A 34 mm Dacron conduit was interposed between the sinotubular junction and the distal ascending aorta. The patient was weaned from cardiopulmonary bypass after a cross-clamp time of 31 minutes, with trivial neo-aortic valve regurgitation. By the following morning, the patient was on minimal ventilator settings, neurologically intact, and had excellent hemodynamic performance and cardiac function. The patient was then returned to the operating room, where a VSRR was performed. The VSRR yielded trivial neo-aortic valve regurgitation at completion of the procedure.