Tutorial

Ross procedure with personalized external aortic root support

Published: November 8, 2023

DOI: 10.1510/mmcts.2023.077

Innovative

The Ross–Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in the aortic position to replace the malfunctioning aortic valve and a homograft is implanted in the pulmonary position. To prevent autograft dilatation, a Personalized External Aortic Root Support prosthesis is included in the proximal autograft anastomosis and wrapped around the ascending aorta. The aorta is transected transversely, the aortic valve is resected, and the coronary arteries are mobilized and cut out of the sinuses, leaving a rim. The pulmonary autograft is harvested by transecting the pulmonary artery and part of the right ventricular outflow tract. The autograft is approximated to the aortic root and inverted inside the ventricle. The proximal anastomosis is performed including the prosthesis between the aortic root and the autograft. The coronary buttons are threaded through appropriately positioned and sized holes in the prosthesis and reimplanted into the autograft. The ascending aorta is appropriately adapted and anastomosed with the distal autograft. When the patient is off cardiopulmonary bypass, the prosthesis can be closed longitudinally and is anchored to the distal aortic adventitia.

Classic approaches for aortic valve replacement in young patients have the essential drawbacks that the patient who receives a mechanical prosthesis will be on lifelong anticoagulation [1] or, in the case of a biologic prosthesis, will likely have to undergo a new aortic valve replacement procedure [2,3]. The Ross procedure has the advantage that the pulmonary autograft is less likely to degenerate than a biological prosthesis [4] and requires no anticoagulation [5]. A potential major limitation of the Ross procedure is the dilatation of the autograft with possible valve insufficiency, which is the main reason for approximately 24%–29.5% of autograft-related reinterventions at 20 years [6,7]. This complication can be prevented by wrapping the autograft in a Valsalva prosthesis [8]. A novel approach is to wrap the autograft and the remaining ascending aorta with a personalized external aortic root support graft, which is custom-made for the patient [9]. We believe that this solution can effectively prevent autograft dilatation. To the best of our knowledge at the time of the writing of this manuscript, outcomes for this procedure have not yet been published.

1 - Patient Presentation (0:12)

Our patient is a 47-year-old male, 187 cm tall and weighing 113 kg, with a bicuspid aortic valve (Sievers type 1 L/R) that was severely insufficient [pressure half time (PHT)=360 ms], a dilated left ventricle and dilatation of the ascending aorta (43 mm). The pulmonary valve was minimally insufficient, the coronary arteries showed no signs of stenosis, and no relevant comorbidities were known. When he was admitted to the hospital, the patient was in sinus rhythm, in good general condition and without dyspnoea. The calculated EuroSCORE II was 1.64%.

For preoperative planning, according to protocol, a computed tomography scan was performed and was used to model and fabricate the prosthesis. The chosen prosthesis size was 115% of the pulmonary artery dimensions.
2 - Separating the aorta and pulmonary artery and evaluating and resecting the aortic valve (1:02)

After a skin incision, a median sternotomy and cannulation for cardiopulmonary bypass (using a properly sized arterial cannula placed in the distal ascending aorta and two venous cannulas placed in the inferior vena cava and the superior vena cava through the right atrial appendage), a retrograde cardioplegia catheter is placed in the coronary sinus, and a vent is inserted into the left ventricle through the right upper pulmonary vein.

The aorta is freed from the pulmonary artery, prepared circumferentially down to the coronaries and cross-clamped; then markings for the possible reduction plasty and transection (5 mm cranially from the right coronary ostium) are made with the tip of a marker. The aorta is transected at the marking and displaced cranially with a holding suture to ensure optimal visibility for the steps that follow. Double-armed 4-0 Prolene sutures are placed at the aortic valve commissures. The valve is inspected to assess for possible reconstruction. If reconstruction is deemed not possible, then the aortic valve leaflets are resected close to the annulus.
3 - Harvesting the autograft and preparing the coronary buttons (1:51)

The pulmonary artery is transected 5 mm under the pulmonary bifurcation, and the right outflow tract is opened on the anterior wall if the valve is deemed appropriate after inspection. Probing the coronary arteries helps to show their path and reduces the risk of injury during preparation. The preparation of the posterior wall needs special care to avoid injuries to the left anterior descending artery and the first septal branch. After harvesting the autograft, meticulous haemostasis of the resection site is mandatory. The autograft is then checked for its integrity.

On the proximal transected aorta, the coronary ostia are marked cranially with 5-0 Prolene sutures, and appropriately sized coronary buttons are cut out of the sinuses. The coronary arteries are then mobilized. The same procedure is applied for both coronary arteries. Bulldog clamps are placed on both coronaries to keep the operating field free from blood.
4 - Proximal anastomosis of the autograft (3:29)

Preparation of the autograft requires removing the epicardial fat tissue on the rims of the proximal cutting line and sizing both the aortic and pulmonary annulus in order to be able to make the necessary adaptations. If the autograft annulus is too wide, it can be reduced with subcommissural sutures between the left and the non-coronary sinus. With the tip of a marker, the commissures of the autograft are marked internally and externally to ease the suturing of the proximal anastomosis.

Three 4-0 Prolene sutures, one on each commissure, are used to approximate the autograft with the aortic root. The posterior sinus of the autograft will be the left coronary sinus of the neo-aortic root. The autograft is then inverted into the ventricle.

Measurements of the prosthesis are performed and compared with those from the preoperative screenings. The commissures are identified on the cast and marked with 5-0 Prolene marking sutures. By pulling the correct string, the prosthesis is opened on its length, then shortened to an approximately appropriate length and removed from its 3-dimensional printed mould.

The proximal anastomosis for the autograft is performed with the sutures used for approximating the two ends and performing a running suture, involving with every stitch the inverted autograft, the aortic root (caudally to cranially) and the prosthesis, so that the prosthesis is held between the aortic root and the autograft. At every commissure, the suture is knotted with the previous one, and the autograft is taken out of the ventricle to check the mobility of the cusps. The last bites in the middle portion of the non-coronary sinus should overlap before tying the suture. Three holding sutures are placed at the commissures on the distal end of the autograft.
5 - Anastomosis of the coronary buttons (7:48)

By pressing the needle holder against the prosthesis on the supposed anastomosis site and approximating it to the coronary buttons, the position is marked, and an approximately 4–5 mm diameter hole is cut in the prosthesis. The coronary buttons are then threaded through the holes. The position for the coronary button is marked with a 6-0 Prolene holding suture, and a hole of the appropriate size is cut. The coronary button is then reimplanted to the autograft with a Prolene 6-0 running suture. Occasional size and shape adaptations can be made to the holes in the prosthesis as needed. The same procedure is performed for both coronary buttons.
6 - Distal anastomosis of the homograft (9:12)

The homograft is inspected for imperfections, and the commissures are marked with the tip of a marker on the distal outer side of the graft. The homograft is then anastomosed to the distal end of the transected pulmonary artery with a 5-0 double-armed Prolene suture in a continuous running fashion.
7 - Distal anastomosis of the autograft (9:42)

To avoid a difficult closure of the prosthesis, three single 3-0 Ethibond stitches are placed but not tied at the proximal end.

The aorta is shortened to fit the interposed autograft. The diameters of the autograft and the aorta are checked with a sizing tool. In case of a mismatch, the angle of one of the ends of the anastomosis can be trimmed to increase the surface and match the other. The distal anastomosis is then tailored with a standard continuous Prolene 5-0 running suture. This patient also needed an aortic reduction plasty, so before placing the last bites, the oversized aorta was opened in its length almost up to the cross-clamp, and a ribbon of the aortic vessel wall was removed in order to reduce the aortic diameter. After reinforcing the T cut with autologous pericardium pledgets, the longitudinal aortotomy was closed in standard fashion with a double row of 5-0 Prolene running suture. The last bites are then loosened to allow for de-airing later.
8 - Proximal anastomosis of homograft (12:15)

Before completing the proximal anastomosis of the homograft, the posterior wall of the right ventricular outflow tract is covered with fibrin sealant to avoid bleeding. The proximal anastomosis is fashioned in the standard way, taking big bites of both ends.
9 -De-airing, unclamping, bleeding control and decannulation (13:07)

Using the previously loosened last loops of the suture for the aortoplasty, the aorta is meticulously de-aired and closed. The aortic cross-clamp is removed, and, after the patient is weaned off cardiopulmonary bypass, the venous cannula is removed, and the surgical site is checked for bleeding.
10 - Closure of the prosthesis (13:33)

The prosthesis is wrapped around the aorta with the help of a Satinsky clamp. At the distal end of the prosthesis, a holding suture is used to keep it in place while the prosthesis is being closed. Then the first three previously placed single sutures for the proximal closure of the prosthesis are tied. The prosthesis is closed from proximal to distal with 3-0 Ethibond single sutures to ensure reliability of the closure in case of a suture failing. The last closing suture as well as some additional sutures are then fixed to the aortic adventitia/pericardial reflection to prevent any displacement of the prosthesis.

Outcome

The patient was haemodynamically stable and in sinus rhythm without need for pacing when he was transferred to the intensive care unit. He was successfully extubated in the afternoon. During the same day, his temperature rose to 38.4°C and slowly decreased during the following day. The low noradrenaline and dobutamine infusions could be stopped, and the patient was transferred to the ward in a satisfactory general condition. Echocardiography showed an excellent postoperative result with good ventricular function and no insufficiency or stenosis of the autograft (Vmax=1.3 m/s) or homograft (Vmax=1.5 m/s). The remaining hospital stay was uneventful, and the patient was discharged on postoperative day 9 in sinus rhythm and in good general condition. Anticoagulation with 6000 IU of low-molecular-weight heparin was continued for 3 weeks.

Discussion

The Personalized External Aortic Root Support (PEARS) procedure for the treatment and prevention of aortic aneurysms has proven to be an effective therapy [10–12]. This approach has been adopted for the prevention of delayed autograft dilatation by modification of the Ross operation. Different techniques for the prevention of an autograft dilatation have been published previously [13,14]. The Ross-PEARS differs from these techniques in several points. First, the prosthesis is tailor-made according to the patient’s own pulmonary artery, facilitating the preservation of an anatomically correct geometry and valve competency. Second, the prosthesis is wrapped around the entire ascending aorta up to the brachiocephalic trunk, not only the root, resulting in stabilization and prevention of further dilatation of the entire ascending aorta. Third, the prosthesis is a pliable mesh and does not isolate the autograft, allowing for potential secretion/oozing, as compared with a straight tube or a Valsalva graft.

We believe that this modification of the Ross procedure is an effective and promising approach for the prevention of postoperative autograft and aortic dilatation.

1. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2022;43:561–632.

Pubmed Abstract | Publisher Full Text

2. Velho TR, Pereira RM, Fernandes F, Guerra NC, Ferreira R, Nobre Â. Bioprosthetic Aortic Valve Degeneration: A Review from a Basic Science Perspective. Braz J Cardiovasc Surg 2022;37:239–50.

PubMed Abstract| Publisher Full Text

3. Werner P, Coti I, Kaider A, Gritsch J, Mach M, Kocher A, et al. Long-term durability after surgical aortic valve replacement with the Trifecta and the Intuity valve – A comparative analysis. Eur J Cardiothorac Surg 2022;61:416–24.

PubMed Abstract | Publisher Full Text

4. El-Hamamsy I, Toyoda N, Itagaki S, Stelzer P, Varghese R, Williams EE, et al. Propensity-Matched Comparison of the Ross Procedure and Prosthetic Aortic Valve Replacement in Adults. J Am Coll Cardiol 2022;79:805–15.

Pubmed Abstract | Publisher Full Text

5. Andreas M, Wiedemann D, Seebacher G, Rath C, Aref T, Rosenhek R, et al. The Ross procedure offers excellent survival compared with mechanical aortic valve replacement in a real-world setting. Eur J Cardiothorac Surg 2014;46:409–14.

PubMed Abstract | Publisher Full Text

6. Oeser C, Uyanik-Uenal K, Kocher A, Laufer G, Andreas M. The Ross procedure in adult patients: a single-centre analysis of long-term results up to 28 years. Eur J Cardiothorac Surg 2022;62.

PubMed Abstract | Publisher Full Text

7. Aboud A, Charitos EI, Fujita B, Stierle U, Reil JC, Voth V, et al. Long-Term Outcomes of Patients Undergoing the Ross Procedure. J Am Coll Cardiol. 2021;77:1412–22.

PubMed Abstract | Publisher Full Text

8. de Kerchove L, Rubay J, Pasquet A, Poncelet A, Ovaert C, Pirotte M, et al. Ross Operation in the Adult: Long-Term Outcomes After Root Replacement and Inclusion Techniques. Ann Thorac Surg 2009;87:95–102.

PubMed Abstract | Publisher Full Text

9. Treasure T, Austin C, Kenny LA, Pepper J. Personalized external aortic root support in aneurysm disease. Curr Opin Cardiol 2022;37:454-8.

PubMed Abstract | Publisher Full Text

10. Van Hoof L, Rega F, Golesworthy T, Verbrugghe P, Austin C, Takkenberg JJM, et al. Personalised external aortic root support for elective treatment of aortic root dilation in 200 patients. Heart 2021;107:1790–5.

Pubmed Abstract | Publisher Full Text

11. Treasure T, Petrou M, Rosendahl U, Austin C, Rega F, Pirk J, et al. Personalized external aortic root support: a review of the current status. Eur J Cardiothorac Surg 2016;50:400–4.

PubMed Abstract |Publisher Full Text

12. Izgi C, Newsome S, Alpendurada F, Nyktari E, Boutsikou M, Pepper J, et al. External Aortic Root Support to Prevent Aortic Dilatation in Patients With Marfan Syndrome. J Am Coll Cardiol 2018;72:1095-105.

PubMed Abstract | Publisher Full Text

13. Jacobsen RM, Earing MG, Hill GD, Barnes M, Mitchell ME, Woods RK, et al. The Externally Supported Ross Operation: Early Outcomes and Intermediate Follow-Up. Ann Thorac Surg 2015;100:631–8.

PubMed Abstract | Publisher Full Text

14. Juthier F, Banfi C, Vincentelli A, Ennezat P-V, Le Tourneau T, Pinçon C, et al. Modified Ross operation with reinforcement of the pulmonary autograft: Six-year results. J Thorac Cardiovasc Surg 2010;139:1420–3.

PubMed Abstract | Publisher Full Text

Authors

Luca Conci¹, Günther Laufer¹, Daniel Zimpfer¹, Alexandra Andreeva¹, Alfred Kocher¹, Conal Austin² & Emilio Osorio-Jaramillo¹

Affiliations

¹Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria

²Cardiac Surgery, Guy’s and St Thomas’ Hospital, London, United Kingdom

Corresponding Author

Emilio Osorio-Jaramillo

Department of Cardiac Surgery

Medical University of Vienna

Vienna

Austria