Ross Procedure After Previous Aortic Valve Repair in an Adult

The authors present a repeat median sternotomy with a Ross procedure after previous aortic valve (AV) repair. This was a 31-year-old man with a BMI of 29 kg/m2 who presented with exertional dyspnea and fatigue. His past medical/surgical history was significant for congenital bicuspid AV stenosis for which he underwent balloon aortic valvuloplasty at 10 years of age, followed by aortic valve repair at age 14. Echocardiography showed bicuspid AV mixed moderate-to-severe stenosis and regurgitation, and he had mild left ventricular enlargement with normal systolic function. The mean gradient across the AV was 30 mm Hg. Catheter pullback across the AV revealed a gradient of 64 mm Hg.<p>After repeat median sternotomy, cardiopulmonary bypass (CPB) was initiated via central aortic and bicaval cannulation. Aortic cross clamp was applied and antegrade cardioplegia was administered. The pulmonary autograft was harvested using electrocautery and trimmed. The aortic root was prepared and coronary buttons were harvested. The autograft was implanted using running 5/0 prolene suture supported with bovine pericardial strips, followed by reimplantation of the coronary buttons in the corresponding sinuses of Valsalva of the neo-aortic root. The authors kept the native noncoronary sinus in place as they believe it provides a hemostatic layer and support for the autograft in this area. To stabilize the neo-sinotubular junction, they replaced a portion of the ascending aorta using a 24 mm hemashield graft.<br></p><p>A decellularized 30 mm pulmonary homograft was used to restore the right ventricular to pulmonary arterial confluence continuity. This was followed by reconstruction of the distal graft to native aortic anastomosis. The heart was then de-aired and the cross clamp was removed. The patient regained his normal sinus rhythm and was weaned off CPB without difficulty. The aortic cross clamp time was 127 minutes, and the cardiopulmonary bypass time was 166 minutes. The patient was extubated a few hours after surgery, received no transfusions, and remained in normal sinus rhythm.<br></p><p>The rest of his hospital course was uneventful and he was discharged home on the sixth postoperative day. Pre-dismissal transthoracic echocardiography showed unobstructed flow across the left ventricular outflow tract with no neo-aortic valve regurgitation or stenosis. The peak gradient across the neo-aortic valve was 4 mm Hg, and it was 17 mm Hg across the pulmonary homograft, and the ventricular function remained normal.<br></p><div>Finally, the Ross procedure remains the best procedure for young patients with active lifestyles due to the excellent hemodynamics, lack of anticoagulation, and absence of patient-prosthesis mismatch.</div><div><p><strong>References</strong><br></p><ol><li>Ross DN. Replacement of the aortic and mitral valves with a pulmonary autograft. <a href="https://doi.org/10.1016/s0140-6736(67)90794-5"><em>Lancet.</em> 1967 Nov 4;2(7523):956-958.</a></li><li>El-Hamamsy I, Eryigit Z, Stevens LM, Sarang Z, George R, Clark L, et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. <a href="https://doi.org/10.1016/s0140-6736(10)60828-8"><em>Lancet.</em> 2010 Aug 14;376(9740):524-531.</a><br></li><li>David TE, Ouzounian M, David CM, Lafreniere-Roula M, Manlhiot C. Late results of the Ross procedure. <a href="https://doi.org/10.1016/j.jtcvs.2018.06.037"><em>J Thorac Cardiovasc Surg</em>. 2019 Jan;157(1):201-208.</a></li></ol></div>