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The Ross Procedure With the Inclusion Technique

Open AccessPublished:July 20, 2022DOI:https://doi.org/10.1053/j.optechstcvs.2022.06.012
      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.

      Keywords

      Central Message
      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.

      Introduction

      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.
      • Ross DN
      Homograft replacement of the aortic valve.
      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.
      • Buratto E
      • Shi WY
      • Wynne R
      • et al.
      Improved survival after the ross procedure compared with mechanical aortic valve replacement.
      Its adoption has been universal in smaller children but remained limited in the adult population.
      • Reece TB
      • Welke KF
      • O'Brien S
      • et al.
      Rethinking the ross procedure in adults.
      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,
      • Juthier F
      • Banfi C
      • Vincentelli A
      • et al.
      Modified Ross operation with reinforcement of the pulmonary autograft: Six-year results.
      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.
      • Elkins RC
      • Thompson DM
      • Lane MM
      • et al.
      Ross operation: 16-year experience.
      ,
      • Klieverik LM
      • Takkenberg JJ
      • Bekkers JA
      • et al.
      The Ross operation: A Trojan horse?.
      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%.
      • Skillington PD
      • Mokhles MM
      • Takkenberg JJ
      • et al.
      The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.
      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.
      • McGiffin David C.
      • Kirklin James K.
      Homograft aortic valve replacement: The subcoronary and cylindrical techniques.
      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).
      Figure 1
      Figure 1If the inclusion technique is favored, the harvesting of the autograft is started by peeling off the fat from the anterior portion of the pulmonary artery and the adjacent pulmonary infundibulum. The origin of the pulmonary arteries and the back of the main pulmonary artery are freed. The main pulmonary artery is divided just proximal to the pulmonary bifurcation. The pulmonary valve is inspected for its suitability as an autograft. A right-angle clamp is used to guide the best site for the initial incision of the subpulmonary conus, allowing for a respectable distance from the nadir of the pulmonary leaflets. This incision is then extended to the left and the right using a combination of scissors and the cautery. As much as possible, cautery is used to free up the posterior aspect of the wall of the pulmonary root. The harvesting proceeds with concomitant peeling of the excess fat tissue surrounding the infundibulum as, in the inclusion technique, the space is limited within the aortic root, especially in the pediatric age. The left lateral part of the harvesting should be conducted with the greatest attention to avoid injury to the first septal perforator branch of the left anterior descending coronary artery. After harvesting, the proximal autograft is trimmed to ensure consistent length of the autograft muscle cuff. The autograft is stored in the posterior pericardium beneath the heart where it bathes within oxygenated blood. The aorta is transected and stay sutures are placed at the coronary commissures. Aortic leaflets are resected. The integrity of the aortic root is preserved.
      Figure 2
      Figure 2The proximal anastomosis is performed with three continuous running Prolene sutures placed mostly in a horizontal plane. 5/0 prolene sutures are used in adults and adolescents and 6/0 sutures in children. Suturing is started in the horizontal plane of the nadir of hingepoints of the leaflets, in the mitral valve at the level of the commissure between the non-coronary sinus left coronary sinus. Suturing then proceed clockwise towards the commissure between the left and the right coronary sinus where another suture is used. Under the commissure between the right coronary and non-coronary sinuses, suturing leaves the horizontal plane to go up in the interleaflet triangle to avoid the conduction tissue. At times the membranous septum can be clearly identified, and we assume that sutures placed above the limit between the muscular tissue and this membranous septum will safely avoid the conduction tissue. A “pulley” suture is looped around every third Prolene suture to ease up the tightening of the sutures. It is essential that the assistant keeps these sutures loose and at the same height before the autograft is parachuted down. This way the maximal exposure of the suture line can be obtained. At this point the “pulley” 4/0 Ethibond sutures sling the Proplene sutures at each sinus to expedite tightening of the anastomosis. Each end of the separate sutures are tied to an another and the proximal anastomosis is completed.
      Figure 3
      Figure 3Retraction sutures are placed on each of the autograft commisures. Gentle traction is maintained on these sutures in order to identify the best location where to implant the coronary ostia. Starting with the left ostium, 2 new orifices are created in the sinuses of the autograft facing the coronary ostia. A sharp knife or a punch hole can be utilized to create these as per surgeon's choice. The left orifice is anastomosed to the left coronary ostium preferably sparing the intimal layer of the coronary. Anastomosis of the right coronary ostium to the new orifice is performed in a similar fashion. This way, the coronaries remain in their position throughout the entire operation and the coronary geometry is preserved as the new orifices are created according to the projections of the coronary ostia.
      Figure 4
      Figure 4The distal pulmonary autograft is trimmed just above the aortic sino-tubular junction as it is known that redundant pulmonary artery tissue will be prone to dilatation. The aortic root wall is similarly trimmed to fit the height of the trimmed autograft. The distal ends of both the aortic and the pulmonary roots are then sutured together.
      Figure 5
      Figure 5The distal anastomosis of the pulmonary homograft to the pulmonary artery bifurcation is performed with 6/0 Prolene suture. Suturing this distal pulmonary anastomosis prior to neo-aorta to ascending aorta anastomosis allows this step to be completed with a better exposure. The proximal anastomosis of the homograft to the right ventricular opening is then completed.
      Figure 6
      Figure 6Lastly, the new aortic root is sutured to the ascending aorta using a continuous Prolene suture. Great care is taken to suture the ascending aorta without distorting the 120 degrees distribution of the 3 commissures. If the aortic root is dilated, anastomosing the ends of the autograft and the native aorta might be stretching the sino-tubular junction. In order to prevent a size mismatch between the neo-aorta and the native ascending aorta and further dilatation of the ascending aorta, a triangular resection and suture-pliacation of the ascending aorta is utilized to match the size of the aortic sino-tubular junction and the ascending aorta.

      Comment

      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.

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      Linked Article

      • Commentary: Three techniques for providing “living” support of the autograft with the Ross operation in children to improve long-term outcome
        Operative Techniques in Thoracic and Cardiovascular Surgery
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          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.
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