Figure 2.

Intraoperative photos of a Ross procedure performed for severe aortic insufficiency in a patient who had undergone prior unroofing of an anomalous right coronary artery (ARCA) and a prior aortic valve (AV) repair. A, Native AV, with pledgeted Prolene suture at the left–right commissure visualized from prior repair and intact tunnel of the unroofed ARCA. B, Native AV, with the left and right cusps detached from the left-right commissure and fibrotic, thickened cusps, making repair infeasible. C, The native AV leaflets have been excised, and the left and right coronary buttons have been mobilized. D, Inspection of the native pulmonic valve revealed a trileaflet valve without fenestrations, suitable for use as an autograft. Here the autograft is being prepared inside a tube graft using the modified inclusion technique. E, The proximal pulmonary autograft has been anastomosed to the aortic annulus, and the right coronary button is translocated to the proper sinus location. F, The pulmonary autograft in situ with left and right coronary buttons reimplanted.