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The Ross procedure is superior as a valve substitute in children and early adulthood because of its clear survival benefits. The free standing-root implantation is associated with failure of the autograft and inclusion techniques that support externally the autograft warrants its longevity. The current technique consists in the implantation of the autograft within the native aortic root thereby both supporting the autograft and avoiding any coronary distortion.
The Ross procedure as free-standing root implantation is prone to significant root dilation and external support has been demonstrated to warrant longevity of the autograft. Supporting the autograft within the intact native aortic root is an easy and safe technique.
In 1967, Donald Nixon Ross, a cardiac surgeon in the National Heart Hospital in London, discontented with the performance of the aortic homografts, pioneered the transplantation of the patient's own pulmonary valve to the aortic position in an operation that now bears his name.
The operation was in his own experience, either a subcoronary graft implantation or the transfer of the entire pulmonary root with subsequent reimplantation of the coronary arteries, as a so-called “free-standing root replacement.” Over his career, he demonstrated that the "living" autograft that was not susceptible to rejection, would grow with the patient while preserving its function and required no lifelong anticoagulation.
The Ross procedure has now proven its superiority as a valve substitute in children and early adulthood because of its clear survival benefits.
The slow adoption of the technique has likely been related to the fact that the procedure required a higher specific training than mechanical or bioprosthetic valve replacement and was fraught with potential technical issues. In the best hands, the Ross procedure has been associated with a 4% rate of early autograft failure,
but many smaller individual experiences were likely fraught with a higher rate of complications. To function properly, the autograft cannot undergo any distortion of its commissures, which leads to early regurgitation.
Distortion of the commissures was the main reason to abandon the subcommissural implantation. The top of the commissures have to be stabilized at the same height at 120 degrees from each other. It was quickly realized that patients with aortic valve regurgitation and large aorto-ventricular junction and those with dilated ascending aorta would see their autograft failing unless the size of these structures was adapted to the size of the matching structures of the autograft. More importantly, in the Ross procedure, the patients are exposed to a higher risk of mortality because of the potential to injure the first septal branch and the LAD during the harvest of the autograft and the potential distortion of the coronary arteries during the reimplantation of the coronary buttons in the free-standing autograft. While these risks are today minimal in expert hands, they are likely to remain as a deterrent for the non-expert.
Over the 2 decades following the adoption of the Ross procedure as free-standing root implantation, it became apparent that many of these patients would see their autograft root dilate significantly. In the best hands, dilation of the free-standing autograft will result in a failure rate of around 25% of these valves within 20 years.
Following the pioneering work of Skillington, it became clear that supporting the autograft by the native aortic root would dramatically improve this issue. Fifteen years after a Ross procedure using his root inclusion technique, the rate of failure of the autograft was reduced to 5%.
In this technique, the annulus was tailored to the size of the autograft, the aorta was often split opened and reconstructed and the coronary arteries are reimplanted in the autograft while crossing a created orifice in the native aortic wall.
We hereby describe a technique that has been adopted early by one of our senior authors Gebrine El Khoury and inspired by technique of a homograft implantation by David C. McGiffin.
In this technique, the entire autograft is sutured inside the intact aortic root. The coronary arteries are not detached but orifices created in the portion of the autograft sinuses facing the coronary ostia are attached to the inside of the native aortic root around the native coronary ostia.
This article depicts the specific technical details of the Ross inclusion technique.
After sternotomy, total cardiopulmonary bypass is initiated using aortic and bi-caval cannulation. Mild hypothermia was established, and the left heart is vented through the right upper pulmonary veins to avoid ventricular distention. Both cavae are snugged down. Following cross clamping of the aorta, transverse aortotomy is performed and antegrade cardioplegia is given directly to the coronary ostia. Olive tip catheters are positioned in the coronary orifices and maintain in position by snaring transmural sutures to avoid coronary retrograde flow. At this stage, the decision to either repair or replace the valve necessitates a meticulous evaluation of the aortic valve. For the non-adult patient group, sustainability of the repair, potential risk of need for reoperation and prolonged re-hospitalization need to be considered. When the decision to proceed with the Ross procedure is made, the operation can be continued as follows (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6).
We have used this technique in the past decade in the pediatric age in children as young as 3 years of age and, more frequently, in young adults and adolescents. We found this technique particularly suited to these ages when the predominant lesion what most call a bicuspid valve, which is probably more accurately described as a unicommissural aortic valve. The majority of these patients have a somewhat dilated aortic root. Some may believe that this dilatation of the aortic root should be a contraindication of the Ross procedure. We have found that in all cases we had an almost perfect match between the inner dimensions of these slightly dilated roots and the outside dimensions of the harvested autografts. We believe that the Ross procedure, as well as the inclusion technique described by Skillington, are feasible. We also find it very reassuring that this technique avoids any potential for coronary distortion because these vessels are not detached and reimplanted, but left in their native position.
In 1967 Donald Ross first described the use of a transplanted pulmonary autograft to replace an aortic valve in twelve patients stating that “As a living autograft, the transplanted pulmonary valve has the prospect of long-term or permanent survival, whilst retaining the advantages of an aortic homograft” the latter being the prevailing implant for aortic valve replacement at that time.1 Fast forward 55 years later, Mr. Ross’ prediction of long-term or permanent survival of the autograft remains controversial, particularly as it is applied to young and rapidly growing children and young infants who arguably would benefit the most from his procedure.