MR#: 1546914
OPERATION: ROSS PROCEDURE (Aortic Valve and Root Replacement using Pulmonary Autograft Conduit with Re-implantation of Coronary Arteries. Right Ventricular Outflow Tract Reconstruction using 30 mm Cryo-Preserved Pulmonary Homograft.)
ANESTHESIA: General Endotracheal
SURGEON: Paul Stelzer, MD
ASSISTANT: Rachel Parker, PA

This 36 year-old man had a history of chronic AR which has been followed for about six years. Over the last six months he has experienced increasing shortness of breath on exertion and even some substernal chest pain on exertion. Echo shows a dilated LV with end systolic dimension of 3.9 and end diastolic dimension of 6.8 cm. Overall systolic function is still pretty good.

He was referred for AVR and specifically asked for the Ross Procedure for which we felt he was an excellent candidate. Cardiac catheterization was performed to assess his coronaries pre-operatively and they were found to be normal in caliber and course. There was severe AR with minimal dilatation of the ascending aorta.

Indeed, at operation we found a bicuspid valve with a rudimentary commissure between the right and left leaflets that had almost completely fused. There was a lot of fenestration of the other two commissures as well. The root itself was only a bit larger than normal, measuring 29 mm in diameter. The ascending aorta was fairly normal in caliber. The pulmonary valve was a superb one with three lovely leaflets and a diameter of 28 mm.

MR#: 1546914

After the patient was anesthetized and intubated with appropriate monitoring established including a radial artery line, a Swan-Ganz catheter, Foley catheter, and Transesophageal Echo, he was prepped and draped in the routine fashion.

A median sternotomy incision was made and the pericardium was opened and suspended with stay sutures in the usual fashion. The great vessels were separated from each other and surrounded with umbilical tapes. The vena cavae were also encircled with tapes. The patient was systemically heparinized and then cannulated in the standard fashion using bicaval technique. Cardiopulmonary bypass was instituted and systemic temperature was taken to 320 C.

The ascending aorta was gently cross-clamped. First some antegrade and then retrograde cold blood cardioplegia solution was infused with excellent myocardial temperature response. Retrograde cardioplegia was repeated at regular intervals and temperature was monitored throughout the procedure. An insulation pad was kept behind the heart. A flexible sucker was used down the root and the pulmonary artery as a vent.

A transverse aortotomy was made and the edges retracted with stay sutures. The valve was excised and the annulus was carefully debrided and measured. The field was irrigated with cold saline.

The pulmonary artery was then transected at the level of the bifurcation and the valve inspected. The pulmonary root was then harvested from the RVOT in the usual fashion taking care to avoid injury to the first septal perforator.

The aortic transection was completed and the coronary artery buttons were mobilized from the root and reflected with stay sutures. The proximal autograft suture line was then constructed with continuous 4-0 Prolene incorporating a strip of felt which had been measured around a 29 mm sizer to make sure that the aorta would not stretch. The autograft fit very nicely. The coronary ostial buttons were then re-implanted in the appropriate sinuses using continuous 6-0 Prolene.

The distal aortic suture line was constructed with continuous 4-0 Prolene incorporating a strip of pericardium measured around a 29 mm sizer. Air was evacuated from the root and antegrade cardioplegia administered demonstrating competence of the valve.

The RVOT was then reconstructed using a cryo-preserved 30 mm pulmonary homograft from a 38 year-old donor. It was an excellent quality graft.

MR#: 1546914
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The posterior half of the proximal anastomosis was reinforced with a strip of the distal homograft tissue. Continuous 4-0 Prolene was used for both proximal and distal suture lines. Warming was begun during the proximal. Warm retrograde blood was administered while the distal suture line was constructed. Air was evacuated from the right side of the heart before the distal suture line was tied.

The ascending aorta was vented and the cross-clamp was removed after a total ischemic interval of 129 minutes. The heart was defibrillated. The pacing wires were placed on the atrium and the ventricle in the usual fashion. Rewarming and reperfusion time was completed while air was evacuated from the apex and the ascending aorta. TEE demonstrated excellent wall motion and valve function with no AR. The LV cavity was already considerably smaller than it was before the procedure.

Ventilation was reinstituted and bypass discontinued after a total pump run of 149'. Good cardiac output and blood pressure were achieved without inotropic support.

Protamine was administered in appropriate dosage and decannulation was accomplished uneventfully. The patient's autologous blood harvested at the beginning of the procedure was returned to him but no other blood products were required. He did receive Aprotinin at the beginning of the procedure. The pericardium was closed loosely. The mediastinum was drained with straight and right-angle chest tubes. The tip of the straight tube was placed in the right pleural space to drain air.

The sternum was then closed with heavy-gauge and after irrigation with antibiotic solution the remaining layers were closed with running Vicryl including subcuticular skin closure. The wound was dressed appropriately.

Pad, sponge, instrument, and needle counts were reported as correct at the end of the procedure and the patient was taken to the recovery area in satisfactory condition having tolerated the procedure well.

Paul Stelzer, MD
D&T: September 16, 1998