Pulmonary autograft with en bloc resection of polyethylene terephthalate aortic graft from prior VSARR.
Central Message.
The Ross procedure is technically feasible after full reimplantation VSARR with a systematic approach to dissection of the aortopulmonary plane.
The Ross procedure, in which a pulmonic valve autograft is implanted to into the aortic valve position, is an ideal solution for young patients with failing aortic valves.1 Although this operation has been successfully utilized following degeneration of previously repaired aortic valves,2,3 reoperation after full valve-sparing aortic root replacement (VSARR) with Tirone David reimplantation technique presents additional technical challenges. Proper deep dissection into the aortic subannular plane required for reimplantation VSARR results in amalgamation of the aortic and pulmonic roots, and the presence of intervening polyethylene terephthalate graft material in this space, especially a graft that is not notched at the left-right commissure, further fibroses and complicates safe dissection near and beneath the pulmonary valve. Thus, reimplantation VSARR might be viewed as a contraindication to subsequent Ross procedure. Here, we present the case of a young patient with a previously repaired bicuspid aortic valve (BAV) and reimplantation VSARR who presented with calcific degeneration and stenosis and underwent a complex reoperative Ross procedure, highlighting key technical strategies to protect the autograft during dissection of this fused anatomic plane. Institutional review board approval not required by university policy. Written consent for publication of images and videos was obtained from the patient.
Case Presentation
The patient is a 41-year-old man with left-right fused BAV who underwent VSARR at an outside institution 13 years prior. Serial echocardiograms revealed gradual reduction in left ventricular ejection fraction from 60% to 47% with increasing aortic valve gradient (23 mm Hg at rest, augmented to 42 mm Hg with stress) and moderate aortic regurgitation. Preoperative transthoracic echocardiogram revealed trace pulmonic regurgitation. Chest computed tomography angiography demonstrated thickened aortic valve leaflets and intact root reconstruction (Video 1). He was referred for aortic valve replacement and, given his young age and active lifestyle, requested reoperative Ross procedure.
The patient was taken to the operating room where he underwent femoral line placement, redo sternotomy, and dissection of mediastinal adhesions. Central aortic and venous cannulas, root vent, and retrograde cardioplegia catheters were placed. Cardiopulmonary bypass was initiated, and the pulmonary artery was transected above the valve commissures. The pulmonic valve was inspected and found to be adequate for autograft use. An left ventricle vent was placed, the aorta crossclamped, and the heart arrested with antegrade and retrograde cardioplegia. The native aorta was transected above the prior graft-to-aorta anastomosis, identifying thickened, sclerotic aortic valve leaflets (Figure 1, A). The coronary buttons were mobilized and the noncoronary sinus portion of the graft was excised to fully open the root (Figure 1, B).
Figure 1.
A, Degenerated, bicuspid aortic valve with thickened leaflets. B, Aortic root after coronary button mobilization and autograft harvest with en bloc resection of a valve-sparing aortic root replacement (VSARR) graft. C, Pulmonary autograft in anatomic orientation with residual VSARR graft material densely adherent before back table sharp resection. D, Proximal suture line during autograft implantation into the Valsalva graft. E, Distal, internal suture line completion with static saline testing of autograft leaflets. F, Completed, implanted autograft composite into the aortic root position.
Autograft explant was initiated by incising the right ventricular outflow tract (RVOT) anteriorly beneath the nonfacing cusp nadir and carrying this incision posterolaterally and counterclockwise beneath the nonfacing sinus. There was no ability to generate a dissection plane between the pulmonic root and the aortic graft at the site of the fused left-right commissure reimplantation; therefore, this portion of the prior VSARR graft was separated on the aortic side and resected en bloc with the pulmonary autograft (Figure 1, C). Then, ex vivo, polyethylene terephthalate and pledget material were sharply resected from the autograft. To achieve this, the autograft was grasped above each commissure and splayed open to maintain its geometry, while the sheet of polyethylene terephthalate material was distracted away from it. A #15 scalpel was then used to shave this material away with the blade pointed toward the polyethylene terephthalate, carefully protecting the autograft. The autograft was trimmed and sized to a 29-mm annular size; therefore, a 32-mm Valsalva graft was selected to conduct the jacketed inclusion technique. The RVOT muscle was anastomosed to the base of the Valsalva graft with running 5-0 Prolene (Ethicon) (Figure 1, D). The commissural posts were then suspended at proper distances and height to achieve symmetric geometry, and the distal autograft anastomosed within the graft with running 5-0 Prolene, resulting in excellent geometry (Figure 1, E).
Returning to the aortic root, the valve leaflets were resected and the annulus debrided. The prior David graft was trimmed down to the level of the annulus, thus intentionally leaving 2 or 3 rings externally in the regions away from the left-right commissure that were resected with the autograft harvest. A set of 4-0 Prolene sutures were placed through the annulus in horizontal mattress fashion, incorporating the prior VSARR graft on the aortic side, then through both the RVOT muscle and graft skirt in the composite autograft. The autograft was seated at the level of the nadirs of the prior VSARR reconstruction, and sutures tied down, resulting in excellent neoaortic valve geometry (Figure 1, F). Left coronary button anastomosis was performed, followed by static pressure testing of the neoaortic valve with antegrade cardioplegia, revealing no leak. The pulmonary artery homograft was prepared. The distal pulmonary artery anastomosis was performed, followed by proximal anastomosis to the RVOT. Aortic reconstruction was then completed with right coronary button reimplantation and graft to native aorta distal anastomosis. Postbypass transesophageal echocardiogram demonstrated excellent neoaortic valve performance with trace regurgitation and mean gradient of 4 mm Hg (Video 2).
Postoperatively, the patient was extubated on the day of surgery, made an uneventful recovery in the hospital, and was discharged home on postoperative day 6. Transthoracic echocardiogram at the time of discharge revealed no neoaortic valve regurgitation, mean gradient of 4 mm Hg, and normal left ventricular function.
Discussion
In principle, the Ross procedure is an attractive secondary intervention for young patients with repaired BAV and subsequent failure. Nevertheless, the additional technical challenge of safely harvesting the pulmonary autograft following full dissection of the aortic root down to the ventriculoaortic junction and intervening graft material in this plane as required for VSARR reimplantation4 may deter surgeons from utilizing this Ross-after-David approach. A previous report by Abeln and colleagues2 demonstrated excellent surgical outcomes for 80 patients undergoing a Ross operation after prior aortic valve repair. This series did not include extensive details of prior aortic valve repair techniques or whether any patients underwent full aortic root replacement. Tamer and colleagues5 specifically reported 2 Ross procedures performed after prior VSARR operations. They reported that separation of the autograft from the polyethylene terephthalate material was feasible and that they utilized the autograft inclusion technique to implant the autograft within the VSARR graft with excellent functional results.
To our knowledge, this is the first report of a Ross with full root replacement technique after prior VSARR. Rather than directly approach the fused, shared subannular space between the autograft and aortic graft, we elected to fully deconstruct the root complex and perform the final separation of autograft and polyethylene terephthalate ex vivo. Several technical aspects of this intraoperative strategy enabled safe autograft recovery. First, although we generally prefer to harvest the autograft and implant the pulmonary homograft with a beating heart (resequenced Ross technique6), aortopulmonary plane obliteration (illustrated in Figure 2, A) rendered typical dissection in this region prohibitively dangerous. With the heart arrested, full mobilization of the coronary buttons and aortic root deconstruction allowed for isolation of the most adherent portion of the graft at the site of the left-right commissure on the aortic side, followed by harvest of the autograft with this portion of the graft and pledget material en bloc (Figure 2, B), thereby minimizing the risk of harm to the autograft. Subsequent ex vivo trimming of this prosthetic material allowed for standard implantation into a Valsalva graft to create an autograft composite for use in the aortic position.
Figure 2.
A, Illustration of operative field in prior valve-sparing aortic root replacement (VSARR) case following aortic transection. The black oval indicates region of dense adhesions between pulmonic root and VSARR polyethylene terephthalate graft and the shadowed white line indicates approximate location of pulmonary valve leaflets. B, En face illustration of cut lines during deconstruction of prior VSARR graft. Coronary buttons are harvested with rim of surrounding polyethylene terephthalate material (red lines) and the connection incision below the left-right commissure (black dashed line) denotes graft/aortic tissue complex resected en bloc with pulmonary autograft.
Collectively, this case highlights the importance of complete familiarity with aortic root anatomy and VSARR operations for surgeons undertaking Ross procedures, particularly in reoperative settings. We conclude that a prior reimplantation VSARR operation does not represent an absolute contraindication to a subsequent Ross procedure.
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
Informed Consent: IRB approval not required. Prospective obtained from patient.
Supplementary Data
Preoperative computed tomography angiography of the chest demonstrating thickened aortic valve leaflets and intact aortic repair. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00356-6/fulltext.
Postbypass intraoperative transesophageal echocardiogram of the neoaortic valve in the long-axis view. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00356-6/fulltext.
References
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Associated Data
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Supplementary Materials
Preoperative computed tomography angiography of the chest demonstrating thickened aortic valve leaflets and intact aortic repair. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00356-6/fulltext.
Postbypass intraoperative transesophageal echocardiogram of the neoaortic valve in the long-axis view. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00356-6/fulltext.