Ross Procedure
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 coumadinfree alternative for aortic valve
replacement across all age groups.
· 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).
· 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.
· More recent concerns regarding autograft dilation and neoaortic
insufficiency have led to further refinements.
· 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.
· A thorough understanding of the anatomic relationships between the
pulmonary and aortic valves is critical (Fig. 17.1).
· 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.
· 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.
· 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.
· Patients with an abnormal pulmonary valve, a complex connective tissue
disease, or an immune complex–mediated disease with known valvular sequelae
should be excluded.
· 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).
· 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).
· After visual inspection of the pulmonary valve leaflets, the pulmonary
root with the valve leaflets is excised from the RVOT. The incision is
initiated in the RVOT across the infundibulum, approximately 4 mm below the
pulmonary valve leaflets. A right-angled clamp can be placed through the
pulmonary valve to identify the proper site to begin the ventriculotomy. The
pulmonary root should be excised with a 3- to 4-mm rim of myocardium (Figs.
17.4 and 17.5).
· Aberrant coronary arteries coursing across the RVOT should be
identified. The dissection extends along the septal myocardium, avoiding the
first septal perforator and left anterior descending artery. The dissection
continues along the course of the left anterior descending artery posteriorly,
avoiding injury to the left main coronary artery (Figs. 17.6 and 17.7).
· After the autograft is harvested, excessive myocardium is excised from
the explanted pulmonary root to avoid LVOT obstruction after implantation (Fig.
17.8).
· A Hegar dilator is gently passed through the pulmonary valve to select
an appropriately sized Dacron tube. We usually pick a tube graft 2 mm larger
than the measured size of the autograft to avoid distortion and narrowing. The
autograft is secured within the tube graft using running 4-0 polypropylene
sutures passed through the myocardium, just below the valve leaflet (Fig.
17.9).
· After the pulmonary root is secured, the graft is cut at the top of the
commissures, and the distal autograft is sutured to the Dacron graft using 4-0
polypropylene (Fig. 17.10). Once the autograft is completely implanted within
the graft, a saline test can confirm leaflet competency (Fig. 17.11).
· The tubularized autograft is sutured to the LVOT using running 3-0
polypropylene (Figs. 17.12 and
17.13). After the proximal anastomosis is complete, the coronary buttons are
reimplanted. A portion of the Dacron conduit and the corresponding internal
autograft sinus are excised after determining the proper location for coronary
reimplantation (Fig. 17.14). The left and right coronary button anastomoses are
performed with 5-0 polypropylene sutures. The coronary buttons create
structural support to the right and left sinuses of the autograft by
stabilizing them to the tube graft. Because of concerns regarding the
nonsupported non-coronary sinus, we suture a piece of homograft inside the
noncoronary sinus to the corresponding wall of the Dacron conduit (Fig. 17.15).
· An appropriately sized pulmonary homograft is used to reconstruct the
RVOT. The distal anastomosis is performed below the bifurcation. The proximal
suture line is completed with 4-0 polypropylene (Fig. 17.16).
· The distal suture of the tubularized autograft is completed (Fig.
17.17).
· Good postoperative care mandates ensuring excellent hemostasis before
leaving the operating room. Any bleeding, especially from the LVOT suture line
or coronary buttons, should be repaired, if necessary, on cardiopulmonary
bypass using cardioplegic arrest.
· Placement of blind sutures at the proximal suture line should be avoided
because autograft leaflets may be injured.
· Transesophageal echocardiography should confirm good valve function and
lack of an LVOT gradient.
· Avoidance of hypertension should be emphasized in the intensive care
unit. Generally, myocardial function is good, and inotropic support is not
necessary.
· Meticulous technique is imperative to avoid bleeding.
· When enucleating the autograft, a definite tissue plane can be
identified between the pulmonary root and surrounding structures. This is most
easily identified by initiating the enucleation on the right (aortic) side of
the autograft.
· Proper alignment of the autograft in the LVOT is mandatory for a
successful outcome.
Bibliography
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