Abstract
The Ross procedure uses the pulmonary autograft to replace the diseased aortic valve and root. With appropriate patient selection and technical modifications, the durability of the autograft can be significantly improved. The Ross procedure continues to be a safe, effective and coumadin-free alternative for aortic valve replacement across all age groups.
Keywords
autograft, aortic root, pulmonary root, inclusion technique, aortic valve replacement
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The Ross procedure replaces the diseased aortic valve with a viable pulmonary autograft and uses an appropriate conduit (e.g., a cryopreserved pulmonary homograft) to reconstruct the right ventricular outflow tract (RVOT).
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As initially described, the autograft was placed as a scalloped subcoronary implant. The complexity of the operation and concerns regarding autograft insufficiency have limited widespread adoption of the procedure. The subsequent use of the full root technique, in addition to the increasing availability of homografts, has increased interest in the operation.
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More recent concerns regarding autograft dilation and neoaortic insufficiency have led to further refinements.
Step 1
Surgical Anatomy
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Relevant surgical anatomy centers on proper enucleation of the pulmonary root and undistorted implantation into the left ventricular outflow tract (LVOT). In adults, we currently place the pulmonary autograft within an appropriately sized Dacron conduit to prevent pulmonary autograft root dilation and subsequent neoaortic insufficiency. This technique also stabilizes the sinotubular junction.
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A thorough understanding of the anatomic relationships between the pulmonary and aortic valves is critical ( Fig. 17.1 ).
Figure 17.1
Step 2
Preoperative Considerations
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The growth potential of the autograft, favorable hemodynamics, and avoidance of anticoagulation have made Ross procedure the operation of choice for infants, children, and adolescents with aortic valve disease requiring aortic valve replacement. It should also be considered for young adults who wish to avoid anticoagulation or who have endocarditis requiring valve replacement.
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We have had excellent results using the Ross procedure in adults with bicuspid aortic valves requiring replacement. Recent evidence has suggested a low rate of RVOT stenosis in older patients, which may extend the popularity of the operation for patients up to the sixth decade.
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It is important to inform patients about the possibility of autograft failure. Avoiding the Ross operation when a significant geometric discrepancy between the pulmonary and aortic annuli is detected preoperatively should minimize this complication. If a moderate-sized discrepancy exists between the aortic and pulmonary roots, a number of techniques to minimize mismatch have been developed; the surgeon should be familiar with them before performing the procedure.
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Patients with an abnormal pulmonary valve, a complex connective tissue disease, or an immune complex–mediated disease with known valvular sequelae should be excluded.
Step 3
Operative Steps
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A standard median sternotomy is performed. The pericardium is incised, and pericardial stay sutures are placed. Bicaval cannulation is used, which facilitates exposure and avoids venous air entrapment following autograft enucleation. Antegrade and retrograde cardioplegia cannulae are placed, except when aortic sufficiency is present, in which case handheld cannulae may be used. The patient is placed on cardiopulmonary bypass and cooled to 32°C (89.6°F). A vent is placed through the right superior pulmonary vein ( Fig. 17.2 ).
Figure 17.2
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The aorta is divided at the sinotubular junction, and the aortic valve is inspected. If no repair option is available, generous coronary buttons are harvested, and the aortic valve and root are excised. The pulmonary artery is transected below the branch pulmonary artery ( Fig. 17.3 ).
