Modified Ross Procedure: Partially Supported Root Replacement

Introduction

The pulmonary autograft was first introduced into clinical practice as a substitute for the diseased aortic valve by Donald Ross in 1967 [[1]]. This technique has become popular due to its excellent hemodynamic performance, low thrombogenicity, and low risk of endocarditis, and because it does not require anticoagulation [[2], [3]]. Furthermore, as the autograft consists of autologous tissue, it continues to grow with the patient. However, there are some concerns regarding the development of a dilatation of the pulmonary autograft and possible autograft regurgitation.

We describe a root replacement method which is a modification of the Ross procedure with partial preservation of the native aortic root. The proposed technique will potentially reduce the risk of long-term pulmonary artery wall dilatation.

Surgical technique

This modified technique was performed in one patient, a 34-year-old man with mixed aortic valve disease. The procedure was carried out with normothermic cardiopulmonary bypass (CPB). Following cross-clamping of the aorta, intermittent, retrograde, hyperkalemic warm blood cardioplegia supplemented with magnesium was administered through the coronary sinus [[4]]. Subsequently, a transverse aortotomy was performed, approximately 1 cm above the sinotubular junction, completely transecting the aorta at this level. Once the diseased aortic valve was excised, the internal diameters of the annulus and the sinotubular junction were measured. The coronary ostia and at least 2 - 3 mm of the surrounding aortic wall tissue were excised as tongues of tissue by making a U-shaped incision at the appropriate location, leaving the remainder of the aortic sinuses intact ([Fig. 1]). The remnants of the aortic root were preserved up to the level of the sinotubular junction. Excision of the pulmonary autograft cylinder was then performed, as previously described by Ross [[1]]. The pulmonary autograft was then inserted into the aortic root as a total root replacement using a 3 - 0 monofilament running suture for the inflow suture line ([Fig. 2]). Incisions were made in the areas of the proposed implantation of the left main and right coronary artery ostia, followed by enlargement of the opening using a 4.0-mm punch. The coronary flaps were reattached to the autograft with a 5 - 0 monofilament running suture as buttons of tissue, and the distal end of the flap was trimmed before completing the suture line. The outflow suture line was placed using a 4 - 0 monofilament running suture, taking special care to incorporate the aortic wall remnant away from the areas above the left and right coronary ostia ([Fig. 3]). The right ventricular outflow tract was reconstructed using an appropriately sized porcine xenograft.

Fig. 1 The coronary ostia are excised as tongues of tissue by making a U-shaped incision at the appropriate location, leaving the remainder of the aortic sinuses intact. Fig. 2 The pulmonary autograft is inserted into the aortic root as a total root replacement. Fig. 3 The outflow suture line is placed, taking special care to incorporate the aortic wall remnant apart from the areas above the left and right coronary ostia.

Postoperative transesophageal echocardiogram performed immediately subsequent to the operation revealed trivial aortic regurgitation. The patient's postoperative recovery was uneventful and he left the hospital 8 days later. Since then he has been seen at 3-monthly intervals, and at 15-months follow up the echocardiography examination demonstrated excellent results with no aortic insufficiency. The diameters of the neo-sinotubular junction, neo-sinuses of Valsalva and neoaortic annulus have not increased.

References

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