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Modified Root Inclusion Technique for the Ross Procedure in Children

  • Igor E. Konstantinov
    Correspondence
    Address reprint requests to: Igor E. Konstantinov, MD, PhD, FRACS, Department of Cardiac Surgery, Royal Children's Hospital, Flemington Rd, Parkville, VIC 3052, Australia.
    Affiliations
    Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia.

    Department of Paediatrics, University of Melbourne, Melbourne, Australia.

    Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.

    Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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  • Edward Buratto
    Correspondence
    Address reprint requests to: Igor E. Konstantinov, MD, PhD, FRACS, Department of Cardiac Surgery, Royal Children's Hospital, Flemington Rd, Parkville, VIC 3052, Australia.
    Affiliations
    Department of Paediatrics, University of Melbourne, Melbourne, Australia.

    Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.

    The Royal Melbourne Hospital, Melbourne, Australia.
    Search for articles by this author
      Autograft stabilization has proven beneficial in adults but the same technique could not always be adopted in growing children undergoing the Ross procedure. The major concern regarding the longevity of autograft after the Ross operation in a growing child is the lack of means to stabilize the aortic root. Herein we described a modified root inclusion technique that achieves aortic root stabilization using autologous tissue.

      Keywords

      Central Message
      The modified root inclusion technique is simple and reproducible, permitting complete wrapping of the native aortic root around the autograft in children. This technique ensures stabilization of the autograft.

      Introduction

      Although aortic valve repair is preferred in growing children,
      • Buratto E
      • Konstantinov IE.
      Aortic valve surgery in children.
      • Wallace FRO
      • Buratto E
      • Naimo PS
      • et al.
      Aortic valve repair in children without use of a patch.
      the aortic valve replacement is sometimes required
      • Myers PO
      • Mokashi SA
      • Horgan E
      • et al.
      Outcomes after mechanical aortic valve replacement in children and young adults with congenital heart disease.
      • Wiggins LM
      • Mimic B
      • Issitt R
      • et al.
      The utility of aortic valve leaflet reconstruction techniques in children and young adults.
      • Baird CW
      • Sefton B
      • Chavez M
      • et al.
      Congenital aortic and truncal valve reconstruction utilizing the ozaki technique: Short –term clinical results.
      with the Ross operation remaining the procedure of choice for aortic valve replacement in a growing child.
      • Donald JS
      • Wallace FRO
      • Naimo PS
      • et al.
      Ross operation in children: 23-year experience from a single institution.
      • Tan Tanny SP
      • Yong MS
      • d'Udekem Y
      • et al.
      Ross procedure in children: 17-year experience at a single institution.
      • Sharabiani MT
      • Dorobantu DM
      • Mahani AS
      • et al.
      Aortic valve replacement and the ross operation in children and young adults.
      • Luciani GB
      • Lucchese G
      • Carotti A
      • et al.
      Two decades of experience with the Ross operation in neonates, infants and children from the Italian Paediatric Ross Registry.
      • Ivanov Y
      • Drury NE
      • Stickley J
      • et al.
      Strategies to minimise need for prosthetic aortic valve replacement in congenital aortic stenosis-value of the ross procedure.
      • Bové T
      • Bradt N
      • Martens T
      The pulmonary autograft after the ross operation: Results of 25-year follow-up in a pediatric cohort.
      However, the autograft is prone to progressive dilatation, and this may contribute to autograft failure.
      • Charitos EI
      • Hanke T
      • Stierle U
      • et al.
      Autograft reinforcement to preserve autograft function after the ross procedure: A report from the german-dutch ross registry.
      In adults and fully grown adolescents, the risk of dilatation can be mitigated by stabilizing the autograft.
      • Skillington PD
      • Mokhles MM
      • Takkenberg JJ
      • et al.
      The Ross procedure using autologous support of the pulmonary autograft: Techniques and late results.
      • Skillington PD
      • Mokhles MM
      • Takkenberg JJ
      • et al.
      Twenty-year analysis of autologous support of the pulmonary autograft in the Ross procedure.
      • Juthier F
      • Banfi C
      • Vincentelli A
      • et al.
      Modified Ross operation with reinforcement of the pulmonary autograft: Six-year results.
      • Buratto E
      • Shi WY
      • Wynne R
      • et al.
      Improved survival after the ross procedure compared with mechanical aortic valve replacement.
      We have recently described various techniques of autograft stabilization for the Ross procedure in children.
      • Buratto E
      • Skillington PD
      • Konstantinov IE.
      Autograft stabilization for the Ross procedure.
      In children, however, stabilization is not straightforward, due to the need to allow somatic growth. We have recently demonstrated that the Ross procedure performed in the re-operative setting in children has a lower risk of autograft reoperation, presumably related to intrinsic stabilization due to increased tissue fibrosis following the previous surgery.
      • Buratto E
      • Wallace FRO
      • Fricke TA
      • et al.
      Ross procedures in children with previous aortic valve surgery.
      Thus, conceptually, it appears that thickened native tissue around the autograft prevents autograft failure in a growing child. Therefore, we try to emulate the same concept in our modified root inclusion technique detailed herein that, in our opinion, is most applicable to a growing child. (Figs. 1-7)
      Figure 1
      Figure 1Exposure of the aortic annulus. The aorta is partially opened leaving the posterior aortic wall above the left coronary artery intact. The aortic valve is removed. Commissural stay stitches and mobilization of the right coronary artery facilitate exposure of the aortic annulus. (Color version of figure is available online at www.optechtcs.com.)
      Figure 2
      Figure 2Reinforcement of the posterior wall of the right ventricular outflow tract. As cardioplegia is given the hemostasis at the site of autograft removal is secured and the posterior wall of the right ventricular outflow tract is reinforced with pledget sutures as it would be difficult to access this area after the Ross procedure. Great caution must be exercised to take superficial bites and avoid distortion of the left main coronary artery. (Color version of figure is available online at www.optechtcs.com.)
      Figure 3
      Figure 3Implantation of the autograft. Implantation of the autograft begins at the nadir of the left coronary cusp. We use 3 separate 4-0 Prolene (Johnson & Johnson, New Brunswick, NJ) sutures starting at the nadir of each cusp to ensure that the autograft is symmetrically implanted, this technique helps to ensure there is no distortion of the autograft. Care must be taken to ensure equal spacing of sutures to minimize the risk of aortic regurgitation. Suture placement should be close to the hinge point of the autograft leaflets, and the autograft should be seated within the native annulus to reduce the risk of annular dilatation. Subsequently, the second layer of 5-0 Prolene circumferential suture is placed to ensure hemostasis. (Color version of figure is available online at www.optechtcs.com.)
      Figure 4
      Figure 4Implantation of the left coronary artery. The left coronary artery is left in situ and implanted into the autograft. Leaving the left coronary artery in its native position eliminated the risk of coronary artery distortion. (Color version of figure is available online at www.optechtcs.com.)
      Figure 5
      Figure 5Implantation of the right coronary artery. The incision is made in the middle of the corresponding sinus of the autograft. The right coronary artery is implanted so that the edges of the autograft are connected to each other above the coronary button to avoid inadvertent enlargement of the sino-tubular junction. (Color version of figure is available online at www.optechtcs.com.)
      Figure 6
      Figure 6Reconstruction and stabilization of the aortic root. The posterior wall of the autograft is sutured to the undivided posterior wall of the native aorta (A). The anterior wall of the autograft is sutured incorporating all 3 layers (i.e., autograft and the edges of the native aorta) into the suture line (B). The suture line at the sino-tubular junction is covered and reinforced with a strip of the autologous pericardium (C). (Color version of figure is available online at www.optechtcs.com.)
      Figure 7
      Figure 7Wrapping of the ascening aorta with autologous pericardium. . The autologous pericardial strip is typically taken from the diaphragmatic surface, where it is strongest. The pericardium is wrapped around the sino-tubular junction and sutured to the ascending aorta. The pericardial strip is tailored so that sino-tubular junction and the echocardiographic annulus of the aortic valve are approximate the same diameter. (Color version of figure is available online at www.optechtcs.com.)

      Discussion

      Several techniques of autograft support have been described, aimed at stabilization of the aortic root that may improve autograft freedom from regurgitation, dilatation, and reoperation.
      • Tan Tanny SP
      • Yong MS
      • d'Udekem Y
      • et al.
      Ross procedure in children: 17-year experience at a single institution.
      ,
      • Charitos EI
      • Hanke T
      • Stierle U
      • et al.
      Autograft reinforcement to preserve autograft function after the ross procedure: A report from the german-dutch ross registry.
      ,
      • Skillington PD
      • Mokhles MM
      • Takkenberg JJ
      • et al.
      The Ross procedure using autologous support of the pulmonary autograft: Techniques and late results.
      ,
      • Tweddell JS
      • O'Donnell AP.
      The externally supported Ross procedure with Konno aortoventriculoplasty.
      We have previously demonstrated that the use of PDS bands to support the STJ in children undergoing the Ross procedure was associated with a reduced incidence of moderate or greater autograft regurgitation (0% Vs 20%, P = 0.04, at a median follow-up 7 years).
      • Tan Tanny SP
      • Yong MS
      • d'Udekem Y
      • et al.
      Ross procedure in children: 17-year experience at a single institution.
      Meanwhile, in adults, it has been shown that autograft stabilization significantly improved freedom from autograft reoperation at 10 years (93% Vs 88%, P = .001).
      • Charitos EI
      • Hanke T
      • Stierle U
      • et al.
      Autograft reinforcement to preserve autograft function after the ross procedure: A report from the german-dutch ross registry.
      However, in a growing child root stabilization involving prosthetic material is problematic. Thus, we describe a simple modified root inclusion technique that stabilizes the aortic root using exclusively autologous tissue. We expect that by avoiding synthetic tissue we can achieve stabilization while preserving a normal growth potential.

      Appendix. Supplementary materials

      References

        • Buratto E
        • Konstantinov IE.
        Aortic valve surgery in children.
        J Thorac Cardiovasc Surg. 2021; 161: 244-250
        • Wallace FRO
        • Buratto E
        • Naimo PS
        • et al.
        Aortic valve repair in children without use of a patch.
        J Thorac Cardiovasc Surg. 2021; 162: 1179-1189
        • Myers PO
        • Mokashi SA
        • Horgan E
        • et al.
        Outcomes after mechanical aortic valve replacement in children and young adults with congenital heart disease.
        J Thorac Cardiovasc Surg. 2019; 157: 329-340
        • Wiggins LM
        • Mimic B
        • Issitt R
        • et al.
        The utility of aortic valve leaflet reconstruction techniques in children and young adults.
        J Thorac Cardiovasc Surg. 2020; 159: 2369-2378
        • Baird CW
        • Sefton B
        • Chavez M
        • et al.
        Congenital aortic and truncal valve reconstruction utilizing the ozaki technique: Short –term clinical results.
        J Thorac Cardiovasc Surg. 2021; 161: 1567-1577
        • Donald JS
        • Wallace FRO
        • Naimo PS
        • et al.
        Ross operation in children: 23-year experience from a single institution.
        Ann Thorac Surg. 2020; 109: 1251-1259
        • Tan Tanny SP
        • Yong MS
        • d'Udekem Y
        • et al.
        Ross procedure in children: 17-year experience at a single institution.
        J Am Heart Assoc. 2013; 2e000153
        • Sharabiani MT
        • Dorobantu DM
        • Mahani AS
        • et al.
        Aortic valve replacement and the ross operation in children and young adults.
        J Am Coll Cardiol. 2016; 67: 2858-2870
        • Luciani GB
        • Lucchese G
        • Carotti A
        • et al.
        Two decades of experience with the Ross operation in neonates, infants and children from the Italian Paediatric Ross Registry.
        Heart. 2014; 100: 1954-1959
        • Ivanov Y
        • Drury NE
        • Stickley J
        • et al.
        Strategies to minimise need for prosthetic aortic valve replacement in congenital aortic stenosis-value of the ross procedure.
        Semin Thorac Cardiovasc Surg. 2020; 32: 509-519
        • Bové T
        • Bradt N
        • Martens T
        The pulmonary autograft after the ross operation: Results of 25-year follow-up in a pediatric cohort.
        Ann Thorac Surg. 2021; 111: 159-167
        • Charitos EI
        • Hanke T
        • Stierle U
        • et al.
        Autograft reinforcement to preserve autograft function after the ross procedure: A report from the german-dutch ross registry.
        Circulation. 2009; 120: S146-S154
        • Skillington PD
        • Mokhles MM
        • Takkenberg JJ
        • et al.
        The Ross procedure using autologous support of the pulmonary autograft: Techniques and late results.
        J Thorac Cardiovasc Surg. 2015; 149: S46-S52
        • Skillington PD
        • Mokhles MM
        • Takkenberg JJ
        • et al.
        Twenty-year analysis of autologous support of the pulmonary autograft in the Ross procedure.
        Ann Thorac Surg. 2013; 96: 823-829
        • Juthier F
        • Banfi C
        • Vincentelli A
        • et al.
        Modified Ross operation with reinforcement of the pulmonary autograft: Six-year results.
        J Thorac Cardiovasc Surg. 2010; 139: 1420-1423
        • Buratto E
        • Shi WY
        • Wynne R
        • et al.
        Improved survival after the ross procedure compared with mechanical aortic valve replacement.
        J Am Coll Cardiol. 2018; 71: 1337-1344
        • Buratto E
        • Skillington PD
        • Konstantinov IE.
        Autograft stabilization for the Ross procedure.
        Op Tech Cardiothorac Surg. 2022; (in press)
        • Buratto E
        • Wallace FRO
        • Fricke TA
        • et al.
        Ross procedures in children with previous aortic valve surgery.
        J Am Coll Cardiol. 2020; 76: 1564-1573
        • Tweddell JS
        • O'Donnell AP.
        The externally supported Ross procedure with Konno aortoventriculoplasty.
        J Thorac Cardiovasc Surg. 2021; 26: 487-509

      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 SurgeryVol. 27Issue 4
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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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