The Ross procedure in 2021—aiming for operative perfection

Generali et al. [1] report their contemporary results with the Ross procedure in this issue of the EJCTS. Importantly, they report excellent survival, as previously observed and referred to as the Ross survival surprise when compared to state-of-the-art aortic valve prostheses. Survival was not influenced by the number of re-operations required on the aortic and pulmonary valve. This has to be compared primarily to the inherent risks of a mechanical prosthesis, which is a lifelong burden and may reduce survival [2]. Therefore, they conclude that the Ross procedure offers excellent results and it should remain part of the strategy to treat children and young adults. Excellent results regarding survival were recently confirmed by the international Ross registry, including 2444 adult Ross patients with an early mortality of 1.0% and a long-term estimated survival of 75.8% after 25 years, which was comparable to the general population [3].

Generali et al. report their experience with a specific operative technique to avoid autograft dilatation and consequent regurgitation of the aortic valve. The routine replacement of the ascending aorta avoids later dilatation of the sinotubular junction and supports the valve geometry, while leaving the sinus area at risk for dilatation. We do agree that shortening of the autograft is a valid option to reduce the risk of reoperation. However, replacement of the ascending aorta leads to a reduction of the Windkessel physiology, rendering the pulmonary autograft to a potentially higher risk of dilatation.

Several techniques and technical steps were previously described to avoid autograft dilatation. The sinotubular junction can be supported with a reduction plasty of the ascending aorta, a ring of Dacron or felt or a replacement of the ascending aorta [4]. However, more importantly, the autograft itself was described to be supported with a mesh of vicryl, the native aorta or included in a Dacron graft [4, 5]. Furthermore, deep implantation of the autograft in the left ventricular outflow tract is beneficial to avoid postoperative dilatation.

We have long-term experience with the Ross procedure in Vienna where this operation has been part of the armamentarium for 30 years and we performed several adaptations of the procedural concept to avoid reoperation [4, 6]. Our current standard operating procedure for the Ross operation is based on the routine inclusion of the pulmonary autograft in a Dacron Valsalva graft and the replacement of the pulmonary valve with a decelluarized or oversized pulmonary valve [7]. Specifically, the autograft is sized with a hegar-dilator and fixed with 3 5/0 polypropylene sutures distally at the commissures to the Valsalva prosthesis (3–5 mm larger than the autograft) at the corresponding areas. The sinus part of the Valsalva prosthesis is shortened to the length of the autograft, often cutting into the sinus area. Thereafter, the proximal end of the autograft and the prosthesis are sewn together with a 5/0 running suture. The graft is implanted deep into the left ventricular outflow tract with 3 4/0 V6 polypropylene running sutures. The coronaries are sewn into the autograft only and not to the prosthesis, which is cut to allow blood to exit the prothesis and avoid haematoma formation between the Valsalva graft and the autograft. The distal anastomosis includes the Valsalva graft. This technique has shown excellent results so far and we hope to avoid autograft dilatation completely.

The technical modifications performed to optimize the Ross procedure by several groups enabled a potentially final treatment for aortic valve pathology in young adults without lifelong anticoagulation. However, the Ross procedure is a complex procedure and requires extensive experience, procedural skills and departmental services (e.g. for homograft harvesting). These aspects make a widespread introduction difficult and hinder the routine application. Therefore, the surgical community is responsible to enhance proctoring and surgical training and provide infrastructure to spread this exquisite technique to provide optimal care for young patients suffering from aortic valve disease. In an optimal setting, it should be performed in specialized ‘Ross Centers’ with access for every patient in need.

Conflict of interest: Martin Andreas is proctor/speaker/consultant (Edwards, Abbott and Medtronic) and received institutional grants (Edwards, Abbott, Medtronic and LSI). The other authors report no conflicts of interest.

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