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Ross preocedure

Ross procedure

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Ross preocedure

  1. 1. ROSS PROCEDURE -Raja Lahiri
  2. 2. 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
  3. 3. 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)
  4. 4. 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
  5. 5. Techniques of insertion • Subcoronary technique • Root inclusion technique • Root replacement technique
  6. 6. 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
  7. 7. • 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
  8. 8. • 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
  9. 9. • 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.
  10. 10. • 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.
  11. 11. • 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
  12. 12. • 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
  13. 13. • 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.
  14. 14. • 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.
  15. 15. • 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
  16. 16. • 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
  17. 17. 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
  18. 18. • 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
  19. 19. • 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
  20. 20. • 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
  21. 21. • 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
  22. 22. • 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.
  23. 23. • 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.
  24. 24. • 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.
  25. 25. • 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
  26. 26. • 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.
  27. 27. 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
  28. 28. • 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.
  29. 29. 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
  30. 30. • 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
  31. 31. 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
  32. 32. 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
  33. 33. 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.
  34. 34. 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
  35. 35. • 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
  36. 36. 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
  37. 37. • 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
  38. 38. • 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
  39. 39. • 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
  40. 40. • 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
  41. 41. 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
  42. 42. 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.
  43. 43. • 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.
  44. 44. Donald Nixon Ross, FRCS (1922 – 2014)

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