3. What is Ross procedure?
• It is a type of aortic valve replacement
whereby the diseased aortic valve is replaced
with the patient’s own normal pulmonary
valve and a biological valve, usually a
pulmonary homograft , is used to replace the
pulmonary valve
4. Indications
• Patients with a life expectancy of more than 20
years
• Patients who cannot safely take or have a lifestyle
not desirous of permanent anticoagulation
• Athletes whose sport requires extended periods
of highly elevated heart rates will also see better
performance with an autograft than a mechanical
valve.
• Infective endocarditis of the aortic valve
• Pediatric age group (also as a part of Ross Konno
procedure)
5. Contraindications
• Marfan's or other genetic disorders known to affect
fibrillin or elastin of the aortic valve: pulmonary valve is
likely to be affected by the same disease process
• Bicuspid aortic valve associated with root enlargement
• Patients afflicted with significant immune-complex
disease (juvenile rheumatoid arthritis, lupus
erythematosus, and active rheumatic heart disease) :
early failure or degeneration of the pulmonary autograft valve
• Patients in these categories have had early failure of
the autograft through dilatation of the root into an
aneurysm and/ or development of aortic insufficiency
7. Operative Technique
• Incision: Standard median sternotomy
• Cannulation: High aortic cannulation + bi-caval
cannulation
• Cardioplegia: Antegrade cardioplegic and
aortic sump line + retrograde coronary sinus
cannula
• Vent: A left ventricular sump is placed via the
right superior pulmonary vein
8. • After initiation of cardiopulmonary bypass,
systemic cooling is started.
• The aorta is clamped, and antegrade blood
cardioplegic solution is administered.
• This is complemented by continuous
retrograde cold blood followed by cold blood
cardioplegic solution
9. • It is of paramount importance that the
pulmonary valve be normal.
• All patients who are considered to be candidates
for aortic valve replacement with a pulmonary
autograft undergo extensive evaluation
preoperatively.
• Nevertheless, it is necessary for the surgeon to
visualize and ascertain the normality of the
pulmonary valve at the outset before committing
to this procedure
10. • A transverse incision is
made on the anterior
aspect of the
pulmonary artery near
the confluence of the
right and left
pulmonary arteries.
• The pulmonary valve is
visualized. It must be a
normal-appearing
trileaflet valve, free of
any disease.
11. • If there is any evidence of pulmonary valve
disease, such as previous endocarditis,
bicuspid leaflets, or the presence of
perforations in the leaflet, the valve is left
intact and the pulmonary artery opening is
closed with 4-0 Prolene suture.
• The aortic valve should then be replaced with
another alternative such as a homograft or
any other appropriate prosthetic valve.
12. • After satisfactory inspection
of the pulmonary valve, a
low transverse aortotomy is
made.
• Cold blood cardioplegia is
administered directly into
the coronary ostia, in
particular the right coronary
artery, for better protection
of the right ventricle.
• Abnormal origin of the
coronary arteries from the
aortic root may complicate
the procedure and requires
some technical
modifications
13. • The aortic valve is
removed and the annulus
debrided of calcium.
• The aorta is transected,
and the left and the right
coronary artery ostia are
both removed with a
large button of aortic
wall.
• The buttons are dissected
free along the course of
the coronary arteries to
ensure their full mobility
• Special care must be
exercised not to injure
any aberrant coronary
arteries
14. • The pulmonary artery is
now completely
transected at the
confluence of its branches
• The dissection is
continued with a low-
current electrocautery,
freeing the pulmonary
artery and its root from
the root of the aorta
down to right ventricular
muscle.
• All small bleeding vessels
are electrocoagulated.
15. • The course of the left main coronary artery is
intimately related to the pulmonary artery and its root.
• Dissection in this area must be carried out with utmost
care.
• Retrograde perfusion of blood through the coronary
sinus identifies small bleeding vessels that otherwise
would have gone unnoticed.
• Hemostasis at this stage of the surgery is important, as
bleeding from this area is difficult to control once the
procedure is completed and the aortic clamp removed.
16. • When the pulmonary
artery is well mobilized, a
right-angled clamp is
introduced into the right
ventricle through the
pulmonary valve.
• An incision is made on
the right ventricular
outflow tract down onto
the right-angled clamp 6
to 8 mm below the
pulmonary valve annulus.
• It is of utmost importance
to prevent any injury to
the pulmonary valve that
is to be used in the aortic
position
17. • This incision is then
extended transversely
across the right ventricular
outflow tract.
• The endocardium on the
posterior aspect of the right
ventricular outflow tract is
incised with a knife 6 to 8
mm below the pulmonary
valve annulus .
• The pulmonary artery is
now enucleated using
Metzenbaum scissors with
the blade angled in such a
way as to not injure the first
septal branch of the left
anterior descending
coronary artery
18. Injury to the First Septal Coronary Artery
• The first septal branch of the left anterior descending coronary
artery has a variable course and may at times be very large.
• The enucleating technique allows detachment of the pulmonary
artery root without injury to this branch, which can lead to
massive septal infarction.
• Some surgeons require patients who are candidates for the Ross
procedure to undergo coronary angiography preoperatively for
the specific delineation of coronary artery anatomy.
• If the first septal artery take-off is very high and its size is
significant, the Ross procedure may be contraindicated.
• If the septal artery is severed, both ends should be oversewn to
prevent fistulous runoff into the right ventricle.
The pulmonary autograft is freed from the right ventricular
outflow tract and is trimmed of excess fatty tissue. It is then
placed in a pool of blood alongside the right atrium
19.
20. • To prevent buttonhole injury
to the pulmonary artery wall,
a finger is carefully placed
inside it across the pulmonary
valve while removing
epicardial fatty tissue.
• Simple interrupted 4-0
Ethibond sutures are now
placed very closely together at
the level of the annulus and
below the level of the
commissures to create a circle
of stitches in a single plane.
• This entails taking bites of the
subaortic curtain, the
membranous, and muscular
segments of the left
ventricular outflow tract.
• The aortic annular sutures are
now passed through the
pulmonary autograft just
below its annulus
21. • Alternatively, the pulmonary autograft can be
anastomosed to the aortic root with a continuous
suture of 4-0 Prolene.
• The suture line should begin at the commissure
between the left and right coronary sinuses, passing
the needle inside out on the aortic annulus and outside
in on the pulmonary autograft.
• The posterior suture line is completed, and then the
second needle is used to complete the anterior
anastomosis.
• A nerve hook may be used to ensure that the suture
line is tight before tying the two ends together
22. • The correct orientation of the
pulmonary autograft is of great
importance.
• It should be placed in such a manner
so that its sinuses overlie the sinuses
of the native aorta to facilitate left
main coronary artery implantation
• When placing sutures in the
pulmonary autograft, care must be
taken not to pass the needle
through the pulmonary valve leaflet.
• The pulmonary autograft is lowered
into position, and the sutures are
tied over a strip of autologous
pericardium
• With the continuous suture
technique, a strip of pericardium
may be incorporated into the
anastomosis
23. • An incision is then made in the
area of the proposed
implantation of the left main
coronary artery button.
• A 4.0-mm punch is used to
enlarge the opening.
• The left main coronary button is
attached to the pulmonary
autograft with 5-0 or 6-0
continuous Prolene suture.
• The right coronary button is
attached to the pulmonary
autograft in the same manner
• There should be no kinking of
the left main coronary artery.
• An appropriately sized probe
must be passed into the left
main coronary artery to ensure
its unobstructed course
24. • It is often prudent to perform the
right coronary attachment after
completion of the distal aortic
anastomosis.
• The aortic clamp can be removed
for a moment to distend the
aortic root and the precise
location of the right coronary
anastomosis can be noted.
• The aorta is clamped again, and
the right coronary artery
anastomosis is completed
• The pulmonary autograft is now
trimmed to meet the transected
ascending aorta and the distal
anastomosis is performed with 4-
0 or 5-0 continuous Prolene
suture
• The aortic cross-clamp can be
removed at this point, and the
reconstruction of the right
ventricular outflow tract
completed while the patient is
being rewarmed.
25. • An appropriately sized,
cryopreserved pulmonary
homograft is selected and
oriented with one sinus
posteriorly and two sinuses
anteriorly in an anatomic
manner.
• It is trimmed appropriately,
and the distal anastomosis is
carried out with 4-0 or 5-0
Prolene suture
• Leaving the pulmonary
homograft too long may result
in kinking of the distal suture
line when the heart is filled
with blood.
26. • There is a tendency for a gradient to develop
across the distal anastomosis.
• This may be secondary to an immune reaction
with subsequent fibrosis.
• It may also be due to the purse-string effect of a
continuous suture line.
• To prevent this complication, sutures should be
spaced close together.
• Additionally, the pulmonary homograft should be
oversized to minimize the gradient even if some
narrowing of the anastomosis occurs.
27. • Using 4-0 Prolene, the
proximal anastomosis is
started on the posterior aspect
of the incision on the right
ventricular outflow tract.
• After completing the suture
line medially, the lateral aspect
of the posterior suture line is
accomplished, taking shallow
bites of the endocardium to
avoid the septal branches of
the left anterior descending
coronary artery
• The remainder of the suture
line anteriorly is completed
• The heart is filled, deairing
performed, and the patient is
weaned from cardiopulmonary
bypass
28. • Full-thickness bites on
the right ventricle
posteriorly risks injury
to high septal coronary
branches.
• The surgeon may elect
to complete the right
ventricle to pulmonary
artery connection with
a pulmonary homograft
before implanting the
pulmonary autograft in
the aortic root.
29. Dilatation of the autograft
• In infants and young children,
implantation of the pulmonary
autograft as a complete root has
been demonstrated to allow
somatic growth to occur.
• The concern is that dilation may
also take place, resulting in aortic
valve insufficiency.
• Excising the entire left and right
aortic sinuses and using this
native aortic tissue to replace the
corresponding sinuses of the
autograft, and reinforcing the
noncoronary portion of the
autograft with the retained native
aortic wall may help prevent
dilation
30. • In older children and adults,
geometric matching of the aortic
and pulmonary artery roots is
necessary to avoid aortic
insufficiency if the root
replacement technique is used.
• This may involve plication of the
aortic annulus with pledgeted
horizontal mattress sutures at the
commissures and/or the use of
an interposition tube graft to fix
the diameter of the sinotubular
junction.
• Alternatively, many institutions
prefer to implant the pulmonary
autograft in older children and
adults using a modified
subcoronary technique, as was
originally performed by Ross.
31. Subcoronary Implantation
• Transverse aortotomy 1 cm above STJ
• Diseased aortic valve excised
• PA opened just before bifurcation & valve
inspected
• Pulmonary root excised 3mm below pulmonary
annulus
• Annular and STJ diameters should be similar
• Posterior pulmonary sinus (smallest) should be
oriented towards left aortic sinus
32. • Pulmonary autograft
secured to LVOT using 4-0
polyester interrupted
sutures
• 3 commisures suspended
in the aortic root and stay
sutures taken through
both arterial walls just
above the commisures
• The right and left facing
sinuses of autograft are
excised and sutured with
5-0 prolene
• Non coronary sinus
sutured to the aortic root
33. Aortic Root Inclusion
• Noncoronary sinus incised vertically
• Pulmonary autograft secured similarly to the
aortic annulus
• 3 commisures are pulled up to determine the
position of right and left coronary orifices
• Small 5-6mm opening made in pulmonary
autograft sinuses facing the coronaries
• Arterial wall of autograft sutured with aortic wall
using 6-0 prolene
• 3 commisures of autograft also sutured to the
aortic wall and aortotomy closed
34. Post op management: Key points
• SBP <110mm Hg
– This continues throughout the stay in the ICU with
IV infusions.
– When the patient tolerates oral intake, oral
antihypertensives are added to the regimen.
– As these are generally younger patients, the lower
blood pressure is nicely tolerated.
– BP managed for atleast 3 months unless the
patient is hypertensive, when lifetime
management is required
35. Post op management: Key points
• NSAIDs
– The pulmonary homograft can cause an intense
postpericardiotomy syndrome, and the addition of
these drugs may help prevent some immune
responses, which could lead to homograft
constriction.
– This phenomenon is also helped by the oversizing
of the homograft
– The nonsteroidals can be discontinued in 3 to 4
weeks.
36. Outcome
• Despite its technical complexity, the operative
mortality associated with Ross procedure is reportedly
low
• It ranges from 0% to 5% and this variation is largely the
result of associated procedures
• Aortic Insufficiency is a serious problem associated
with technical errors
• Thromboembolic complications are rare esp after the
autograft is healed in the aortic root
• Risk of Infective endocarditis is also very low
• Subaortic false aneurysm is rare, but it may occur in
the first post operative year
37.
38. • Annual doppler echocardiography to assess the
function of the neo-aortic and pulmonary
homograft and to measure the size of aortic root
• Long term survival is excellent
• Late aortic insufficiency is caused by dilatation of
the pulmonary autograft
• Aneurysm of the sinuses of the autograft have
been described
• Stenosis of the pulmonary homograft is also seen
which may require percutaneous balloon
dilatation with stenting or re-replacement
39. Ross II procedure
• Implantation of pulmonary autograft in the mitral position
• The patient is placed on cardiopulmonary bypass with bicaval
cannulation
• An 8-cmx8-cm pericardial patch is prepared with a 2.5-cm hole in
the center
• Either a left atriotomy or a transseptal approach (depending on the
size of the left atrium) is used to explore and evaluate the mitral
valve
• The pulmonary autograft is removed in a classic fashion
• The new mitral valve is prepared with either a collar of pericardium
(top hat procedure) or alternatively without.
• The pulmonary autograft is inserted inside a Dacron conduit (2.5-
cm long) by the assistant, while the surgeon reconstructs the right
ventricular outflow
40. • The autograft is attached to the Dacron
conduit with temporary stay sutures
placed both proximally and distally.
• The pericardial collar is then passed
inside the autograft, and the edge of the
pericardium is attached with stay sutures
on the Dacron.
• The rim of the pericardial orifice is
attached to the proximal part of the
Dacron with a running suture including
the pericardium, valve rim, and Dacron, in
that order
• Another running suture is used to attach
the distal part of the pulmonary autograft
on the Dacron
• The mitral valve is excised, making an
effort to preserve the attachments of the
papillary muscles in the mitral annulus
• Insertion of the “new mitral valve” by
suturing the distal part of the Dacron
onto the mitral annulus and pericardial
collar on to the left atrial wall is
performed, avoiding the pulmonary vein
orifices
41. • Modifications of this technique have been described by
Kabbani (removal of the pericardial collar and use of a
more rigid version of Dacron) and by Kumar (use of
scalloped stent of felt for external support of the
autograft)
• The features of this modification that may improve
outcome are a reduced operative time and a lower risk
of pericardial collar rupture, both of which make
potential reoperation easier
• An added advantage is that the creation of a dead
space between the pericardial collar and atrial wall is
avoided, thereby reducing the risk of both thrombus
formation and kinking of the Dacron tube, such as in
the case of a paravalvular leak
42. • The drawback of this modification is that it leaves
the conduit uncovered in the left atrium,
increasing the risk of thromboembolism because
of exposure of blood in the left atrium to foreign
material. This is particularly relevant in patients
with atrial fibrillation, who are already prone to
thromboembolic disease
• In Kumar’s modification, the stent from the thick
Teflon felt does not come in contact with the
blood stream, and therefore this does not carry
the previously mentioned thromboembolic risk
43. • In patients with congenital stenosis, the Dacron tube
does not allow the annulus of the mitral valve to grow
with the child
• To counter this, Kabbani has described leaving the
Dacron tube slit open along one or both sides
• A “loose fit” will allow the new mitral substitute to
function in a more physiologic way, with the autograft
sinuses allowed to expand during systole
• Complications associated with the procedure include
– autograft stenosis resulting from kinking of the Dacron
tube. This is caused by the use a softer variety of Dacron as
well as inadequate removal of the posterior subvalvular
apparatus.
– rupture of the pericardial collar that requires reoperation
44. Pulmonary Homograft
• There are various methods of using and preserving the
pulmonary homograft-
– Fresh cadaveric homograft
– Cryopreservation
– Sterilisation by ethylene oxide/gamma irradiation followed
by storage in nutrient/antibiotic solution
• Although numerous studies have been done comparing
the methods, all yield conflicting evidences regarding
which option is better
• Pulmonary stenosis due to homograft failure is late to
develop and well tolerated by the low pressure system
of the right heart
• ABO and Rhesus compatibility confer no specific
advantage regarding the immune responses
45. Conclusion
• The ideal approach to managing aortic valve
disease in the young patient remains
controversial. Although valve repair should be
considered, it is frequently not anatomically
possible, especially in the setting of aortic
stenosis.
• The requirements for aortic valve replacement
(AVR) in the young patient are simple—the
replacement should be durable, not require
anticoagulation, and have a very low incidence of
stroke and other valve-related complications.
46. • The pulmonary autograft procedure for replacement of
the aortic valve (Ross procedure) has the potential
advantage of freedom from thromboembolism without
the need for anticoagulation, excellent hemodynamic
performance, growth over time, and the assumption
that replacement of the aortic valve with a living
autologous tissue is preferential to prosthetic or
xenogenic materials
• Unfortunately, this procedure is technically complex,
and potentially creates both aortic and pulmonary
valve disease.
• Results with the procedure have also proven difficult to
translate to the broad cardiac surgery community
• It is perhaps unfortunate that the Ross procedure is so
technically demanding and has proven so difficult to
reproducibly teach, as one could argue that in the right
hands it is an excellent option in the young patient in
need of an AVR.
