Ross Procedure With Modified Inclusion Technique: An Autograft in a Vest

The patient was a 13-year-old boy who was born with a congenital unicuspid or bicuspid aortic valve. He developed progressive aortic valve stenosis and became symptomatic. The decision was made to proceed with the Ross procedure. 

Through median sternotomy, cardiopulmonary bypass (CPB) was initiated via aortic and bicaval cannulation. After cardioplegic arrest, the autograft was harvested and prepared in the standard fashion. The aorta was transected, and both coronary buttons were harvested and mobilized in a way that left the remaining aortic root tissue and sinotubular junction intact. The aortic annulus was enlarged posteriorly following Nicks' principle, and the area was augmented with an autologous nontreated pericardial patch. The autograft was then implanted with a running 4-0 polypropylene suture, and a second running hemostatic layer was performed as well. The coronary buttons were implanted in the usual manner. This was followed by the completion of the aortic root-to-distal native aorta anastomosis. The right ventricular outflow tract (RVOT) was reconstructed with a 23 mm xenograft. 

The heart was deaired, and the aortic cross-clamp was removed. The patient restored sinus rhythm, and the completion of the RVOT reconstruction was accomplished. Weaning off CPB was uneventful, and the vest around the autograft was completed by suturing the autologous pericardial patch to the remaining aortic tissue. 

The postoperative course was uneventful, and the postoperative echocardiogram showed a competent autograft valve and widely patent RVOT and left ventricular outflow tract. This technique is very valuable, especially in the pediatric population, where autologous support of the autograft is needed to provide stabilization and prevent future dilation of the autograft, which has been the Achilles' heel of this operation in children. It is also a more reproducible strategy compared to the subcoronary implantation technique. 

References

1. Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. Lancet. 1967 Nov 4;2(7523):956-958.
2. Konstantinov I., Buratto E. Modified Root Inclusion Technique for the Ross Procedure in Children. Op Tech Thoracd Cardiovasc Surg. 2022; 27, Issue 4: 405-413
3. Afifi A, Hosny H, Mahgoub A, Yacoub M. The Ross procedure—the loose jacket technique. Ann Cardiothorac Surg. 2021 Jul;10(4):544–545.

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