Ross Procedure after Explantation of Failed Transcatheter Aortic Valve Replacement

The patient is a forty-six-year-old man with a history of a bicuspid aortic valve. He underwent a transcatheter aortic valve replacement (TAVR) two and a half years prior for symptomatic aortic stenosis at an outside hospital. He presented with increasing shortness of breath, fatigue, and lightheadedness. An echocardiogram identified severe prosthetic aortic valve stenosis with peak gradient 57 mmHg, mean gradient 41 mmHg, and aortic valve area 0.62 cm2.

Through a median sternotomy with bicaval cannulation and antegrade Del Nido cardioplegic arrest, the TAVR valve was explanted. This was followed by the Ross procedure, using a pulmonary autograft-in-conduit technique with a 30 mm Gelwave graft and reconstruction with a 29 mm pulmonary homograft. A concomitant cryomaze procedure and left atrial appendage exclusion with a 40 mm AtriCure clip were also performed.

A post-bypass transesophageal echocardiography revealed normal biventricular function with no neoaortic or pulmonic valve insufficiency. At his three-month follow-up, the patient was doing well. A repeat transthoracic echocardiogram demonstrated a normal neoaortic valve with no regurgitation, peak gradient 8 mmHg, mean gradient 4 mmHg, and aortic valve area 2.6 cm2. There was also normal function of the pulmonic valve with trace physiologic regurgitation.

Reference(s)

1. El-Hamamsy I, Toyoda N, Itagaki S, et al. Propensity-Matched Comparison of the Ross Procedure and Prosthetic Aortic Valve Replacement in Adults. J Am Coll Cardiol. 2022;79(8):805-815.