Protected Ross technical diagram.
Central Message.
The protected Ross technique of encasing the autograft in a Dacron sleeve is an effective and reproducible mechanism to strengthen and stabilize the autograft and may prevent autograft dilation.
The Ross procedure has demonstrated long-term survival similar to matched cohorts in the general population.1 While reintervention rates after the Ross procedure compare favorably to rates after bioprosthetic aortic valve implantation, approximately 20% of Ross patients will require autograft reintervention after 20 years.1, 2, 3 Reinterventions are driven primarily by autograft dilation and aortic insufficiency (AI). Modifications introduced with the aim of reducing the risk of AI include deep root implantation, external ring annuloplasty, and strict blood pressure control. One technique is to encase the autograft in a vascular conduit, which has been shown to reduce autograft failure from 35.2% to 5.2% over 10 years in the setting of a native bicuspid aortic valve.4 This technique may decrease autograft elasticity, increase gradients, cause peri-autograft inflammation, and complicate coronary reimplantation, however, and thus we reserve it for patients at increased risk of autograft dilation.
Technique
The protected Ross procedure begins with standard circumferential aortic root preparation for valve replacement. Coronary buttons are harvested in a standard fashion. In cases of bicuspid aortic valve, the aortic annulus is often asymmetric and must be circularized. A symmetric, nearly planar annulus can be formed via closure of the commissures superior to the level of the aortic annulus and creation of 3 equal sinuses 120-degrees apart. In the setting of endocarditis, the annulus can and should be reconstructed with a bovine pericardial patch.
The pulmonary autograft is harvested, and all but 2 to 3 mm of muscle is trimmed inferiorly (Video 1). The external Dacron graft is sized by adding 10 mm to the average geometric heights of the autograft leaflets. We prefer the Cardioroot graft for its flexibility. The bottom skirt of Dacron is trimmed, and the autograft is placed inside the graft. Incisions are made approximately 3-mm above each commissure in the autograft.
Autograft commissures are resuspended at or above the level of the sinotubular junction inside the graft, and the subcommissural triangles are sutured at marked 120-degree increments (Figure 1). The proximal autograft is secured with running 4-0 suture tied at each commissure. Symmetry is assessed, and commissural resuspension height is adjusted as needed (Video 2, Figure 2).
Figure 1.
Autograft commissural resuspension inside a Dacron graft.
Figure 2.
Securing the autograft into the Dacron graft.
The protected autograft is implanted in the aortic annulus with running suture, starting a new suture at each commissure. If the nonsinus appears deep relative to the left and right sinuses, the sutures should be allowed to come out high on the aortic wall to preserve symmetry. After sutures are placed, the autograft is seated in the annulus and sutures are tightened and tied.
The coronary arteries are reimplanted before the distal suture line is completed. A hole is made in the Dacron graft, and a trapdoor incision is made from superior to inferior in the appropriate spot on the autograft. Coronary anastomosis is performed using a “tongue” technique (Figure 3). The suture is initially passed from inside to out on the coronary button, then inside to out on the distal aspect of the tongue of autograft tissue, then outside to in on the Dacron graft. This technique pulls the tongue of autograft tissue over the Dacron and prevents direct coronary to Dacron contact. Importantly, the hole in the Dacron must be slightly larger than the autograft trapdoor. An overly large autograft incision makes it challenging to include Dacron and autograft in each stitch during coronary reimplantation.
Figure 3.
Coronary reimplantation via the “tongue” technique.
The distal Dacron is folded externally to the level of commissural resuspension, and locking 4-0 Prolene is used to suture the distal autograft to the Dacron, leaving a segment of distal Dacron for the aortic anastomosis (Figure 4). Following autograft implantation, antegrade cardioplegia is given to assess valve competence and hemostasis. Finally, an appropriately sized pulmonary homograft is selected and implanted in a standard fashion (Video 3).
Figure 4.
Completed protected autograft implantation.
This technique of autograft stabilization by encasing the autograft inside a Dacron graft in the Ross procedure offers an additional level of protection compared to our previously reported “Seattle shawl” procedure.5 In addition to preventing autograft dilation, the protected Ross technique allows for assessment and adjustment of the autograft to promote symmetry and valvular competence. Some surgeons have concerns regarding long-term viability of the living tissue autograft inside Dacron. Further investigation is needed to determine if and to what degree the protected Ross technique may limit autograft dilation, prevent late AI, and improve long-term outcomes.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
Institutional Review Board approval was not necessary for this study, and the need for informed consent was waived.
Supplementary Data
Aortic root and coronary button preparation and autograft harvest. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00359-1/fulltext.
Implanting the autograft inside the Dacron graft. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00359-1/fulltext.
Implantation of the protected autograft, coronary anastomosis, and distal aortic anastomosis. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00359-1/fulltext.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Aortic root and coronary button preparation and autograft harvest. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00359-1/fulltext.
Implanting the autograft inside the Dacron graft. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00359-1/fulltext.
Implantation of the protected autograft, coronary anastomosis, and distal aortic anastomosis. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00359-1/fulltext.