eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiothoracic Surgery

Aortic Valve Disease and the Ross Operation: Treatment

Author: Bahaaldin Alsoufi, MD, Consulting Surgeon, Department of Pediatric Surgery, King Faisal Heart Institute, King Faisal Specialist Hospital and Research Centre
Coauthor(s): Christopher A Caldarone, MD, Associate Professor, Department of Surgery, The Hospital for Sick Children, University of Toronto; Gregory B Dalshaug, MD, Assistant Professor, Division of Cardiovascular Surgery, Royal University Hospital
Contributor Information and Disclosures

Updated: Jan 28, 2009

Treatment

Preoperative Details

Echocardiography is used preoperatively to assess the aortic valve pathology, levels of left ventricular outflow tract obstruction and associated cardiac abnormalities. The pulmonary valve is assessed for clinically significant regurgitation or any other pathology. Echocardiography is also useful for assessing the sizes of the aorta and pulmonary annulus. A disparity in size of more than 2-3 mm is likely to require augmentation or reduction in the diameter of the aortic annulus.

Intraoperative Details

All procedures are performed though midline sternotomy. Cardiopulmonary bypass is established via standard aortic and bicaval venous cannulation. The left ventricle is decompressed by venting through the right superior pulmonary vein. Mild hypothermia (32-34 º) is used with a combination of antegrade and retrograde cold blood cardioplegia. Antegrade cardioplegia is initially administered through the root and then by direct coronary artery cannulation at 20-minute intervals.

The aorta is transected 1.5 cm above the right coronary artery. The aortic valve is inspected and repaired, if possible. If the valve is not repairable, the leaflets are then completely excised and calcium is debrided if present. The main pulmonary artery is partially opened just proximal to the bifurcation, and the valve is inspected to ensure normal anatomy and function.

Once the decision is made to proceed with the Ross procedure, the coronary buttons are prepared. A generous rim of aorta is left around each ostium to allow for suturing to the pulmonary autograft later.

The pulmonary artery is separated from the aorta up to the bifurcation and is completely divided (see Media file 3). The autograft is harvested by placing a right-angled clamp through the valve and by bringing the tip through the infundibulum approximately 1 cm below the base of the cusps (see Media file 4). The right ventricular outflow tract is then opened circumferentially using scissors. Once the dissection proceeds laterally, the left anterior descending artery and its first septal branch are at risk if meticulous dissection is not performed (see Media file 2). Following harvesting of the autograft, retrograde cardioplegia is administered and small venous branches are cauterized or ligated in the bed of the harvested autograft.

The autograft and the right ventricular outflow tract are then sized with standard sizers to select an appropriate-sized pulmonary homograft to be prepared. The aortic root annulus is also sized to determine if any discrepancy needs to be addressed. An annular size difference of 2-3 mm is well tolerated. If the aortic annulus is too large, reduction is best achieved with an imbricating suture passed circumferentially at the level of the annulus and tied over a dilator the size of the pulmonary autograft. Alternatively, a series of mattress sutures can be used with care to avoid the region of the conduction system. If the aortic root annulus is too small, then an aortoventriculoplasty combined with the Ross procedure (commonly known as a Ross-Konno procedure) is appropriate (see Media files 8-9).

The autograft is sutured to the aortic valve annulus using either a running or interrupted 4-0 polypropylene suture. If no further growth is required, the sutures are tied around a circumferential strip of Teflon felt approximately 3 mm wide (see Media file 5). The graft should be orientated so that the commissures of the autograft line up with the commissures of the excised aortic valve. A small opening is made in the left coronary sinus of the autograft, and the left coronary artery is anastomosed using a running 6-0 polypropylene suture. The distal aortic anastomosis is then constructed with a continuous 4-0 polypropylene suture.

The aortic root is deaired and insufflated to test the suture lines and to allow proper placement of the right coronary artery once the autograft is distended. The anastomosis is constructed in a similar fashion as the left coronary button. Antegrade cardioplegia can now be administered, and bleeding in the bed of the harvested autograft site can be addressed.

A cryopreserved pulmonary homograft is then appropriately trimmed, and the distal anastomosis is performed using a continuous 4-0 polypropylene suture. The proximal anastomosis is then constructed with continuous 5-0 polypropylene (see Media file 6).

The patient is then placed in steep Trendelenburg position. While the aortic and left ventricular vents are aspirated, the cross-clamp can be removed. The remainder of the anterior portion of the homograft anastomosis can be completed with the heart beating.

The patient is then weaned from cardiopulmonary bypass; protamine is administered, and the patient is decannulated. Transesophageal echocardiography is used to assess the function of the autograft and the homograft once the procedure is complete (see Media file 7).

The autograft implantation technique described is the miniroot reimplantation technique. It is the preferred implantation strategy used at the authors' institution. Other implantation techniques are similar to those described for homografts, such as the subcoronary and the cylinder inclusion techniques, and are preferred by some surgeons. In the Ross registry database, 81% of autografts were implanted using the root technique, whereas 11% used the subcoronary technique, and 6% used the inclusion technique.4

Postoperative Details

Standard postoperative cardiac management is administered. Patients can generally be weaned from ventilatory support in the early postoperative period, the exception is a neonate who was critically ill before surgery.

Follow-up

Patients are examined 4 weeks postoperatively to address any surgical issues. They should also continue to undergo biannual echocardiography to assess function of the right- and left-sided semilunar valves. After undergoing surgical repair of aortic valve disease, patients are given antibiotics to prevent endocarditis before they receive any procedures that may cause bacteremia. For more information, see Antibiotic Prophylactic Regimens for Endocarditis.

More on Aortic Valve Disease and the Ross Operation

Overview: Aortic Valve Disease and the Ross Operation
Treatment: Aortic Valve Disease and the Ross Operation
Follow-up: Aortic Valve Disease and the Ross Operation
Multimedia: Aortic Valve Disease and the Ross Operation
References
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References

  1. Lower RR, Stofer RC, Shumway NE. Autotransplantation of the pulmonic valve into the aorta. J Thorac Cardiovasc Surg. 1960;39(5):680-7. [Medline].

  2. Pillsbury RC, Shumway NE. Replacement of the aortic valve with the autologous pulmonic valve. Surg Forum. 1966;17:176-7. [Medline].

  3. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. Nov 4 1967;2(7523):956-8. [Medline].

  4. Oury JH, Hiro SP, Maxwell JM, et al. The Ross Procedure: current registry results. Ann Thorac Surg. Dec 1998;66(6 Suppl):S162-5. [Medline].

  5. Pasquali SK, Cohen MS, Shera D, Wernovsky G, Spray TL, Marino BS. The relationship between neo-aortic root dilation, insufficiency, and reintervention following the Ross procedure in infants, children, and young adults. J Am Coll Cardiol. May 1 2007;49(17):1806-12. [Medline].

  6. Alexiou C, McDonald A, Langley SM, et al. Aortic valve replacement in children: are mechanical prostheses a good option?. Eur J Cardiothorac Surg. Feb 2000;17(2):125-33. [Medline].

  7. Alsoufi B, Al-Halees Z, Manlhiot C, et al. Mechanical valves versus Ross procedure for aortic valve replacement in children: Propensity-adjusted comparison of long-term outcomes. J Thorac Cardiovasc Surg. 2009.

  8. Al-Halees Z, Pieters F, Qadoura F, et al. The Ross procedure is the procedure of choice for congenital aortic valve disease. J Thorac Cardiovasc Surg. 2002;123:437-41. [Medline].

  9. Albertucci M, Karp RB. Aortic valvular allografts and pulmonary autografts. In: Emunds LH, ed. Cardiac Surgery in the Adult. New York, NY: McGraw-Hill; 1997:911.

  10. Alsoufi B, Karamlou T, Bradley T, Williams WG, Van Arsdell GS, Coles JG. Short and midterm results of aortic valve cusp extension in the treatment of children with congenital aortic valve disease. Ann Thorac Surg. Oct 2006;82(4):1292-9; discussion 1300. [Medline].

  11. Berger S, Dhala A, Friedberg DZ. Sudden cardiac death in infants, children, and adolescents. Pediatr Clin North Am. Apr 1999;46(2):221-34. [Medline].

  12. Brown JW, Ruzmetov M, Vijay P, et al. Clinical outcomes and indicators of normalization of left ventricular dimensions after Ross procedure in children. Semin Thorac Cardiovasc Surg. 2001;13:28-34. [Medline].

  13. Brown JW, Ruzmetov M, Vijay P, et al. Surgery for aortic stenosis in children: a 40-year experience. Ann Thorac Surg. 2003;76:1398-1411. [Medline].

  14. Chambers JC, Somerville J, Stone S, Ross DN. Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series. Circulation. Oct 7 1997;96(7):2206-14. [Medline].

  15. David TE, Omran A, Ivanov J, et al. Dilation of the pulmonary autograft after the Ross procedure. J Thorac Cardiovasc Surg. 2000;119:210-20. [Medline].

  16. Elkins RC, Knott-Craig CJ, Ward KE, Lane MM. The Ross operation in children: 10-year experience. Ann Thorac Surg. Feb 1998;65(2):496-502. [Medline].

  17. Elkins RC, Santangelo K, Randolph JD, et al. Pulmonary autograft replacement in children. The ideal solution?. Ann Surg. Sep 1992;216(3):363-70; discussion 370-1. [Medline].

  18. Elkins RC, Thompson DM, Lane MM, Elkins CC, Peyton MD. Ross operation: 16-year experience. J Thorac Cardiovasc Surg. Sep 2008;136(3):623-30, 630.e1-5. [Medline].

  19. Fedderly RT. Left ventricular outflow obstruction. Pediatr Clin North Am. Apr 1999;46(2):369-84. [Medline].

  20. Gerosa G, McKay R, Davies J, Ross DN. Comparison of the aortic homograft and the pulmonary autograft for aortic valve or root replacement in children. J Thorac Cardiovasc Surg. Jul 1991;102(1):51-60; discussion 60-1. [Medline].

  21. Hazekamp MG, Grotenhuis HB, Schoof PH, et al. Results of the Ross operation in a pediatric population. Eur J Cardiothorac Surg. 2005;27:975-79. [Medline].

  22. Hraska V, Krajci M, Haun C, et al. Ross and Ross-Konno procedure in children and adolescents: mid-term results. Eur J Cardiothorac Surg. 2004;25:742-47. [Medline].

  23. Jahangiri M, Nicholson IA, del Nido PJ, et al. Surgical management of complex and tunnel-like subaortic stenosis. Eur J Cardiothorac Surg. 2000;17:637-42. [Medline].

  24. Joyce F, Tingleff J, Pettersson G. Changing indications for the Ross operation. Semin Thorac Cardiovasc Surg. Oct 1996;8(4):336-44. [Medline].

  25. Kalangos A, Beghetti M, Baldovinos A, et al. Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency. J Thorac Cardiovasc Surg. Aug 1999;118(2):225-36. [Medline].

  26. Karamlou T, Jang K, Williams WG, Caldarone CA, Van Arsdell G, Coles JG. Outcomes and associated risk factors for aortic valve replacement in 160 children: a competing-risks analysis. Circulation. Nov 29 2005;112(22):3462-9. [Medline].

  27. Khwaja S, Nigro JJ, Starnes VA. The Ross procedure is an ideal aortic valve replacement operation for the teen patient. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005;173-5. [Medline].

  28. Konno S, Imai Y, Iida Y, et al. A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring. J Thorac Cardiovasc Surg. Nov 1975;70(5):909-17. [Medline].

  29. Kouchoukos NT, Davila-Roman VG, Spray TL, et al. Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic-valve disease. N Engl J Med. Jan 6 1994;330(1):1-6. [Medline].

  30. Kouchoukos NT, Masetti P, Nickerson NJ, et al. The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg. 2004;78:773-81. [Medline].

  31. Latson LA. Valvar, supravalvar, and fibromuscular subvalvar. In: Garson A Jr, Bricker JT, Fisher DJ, Neish SR, eds. The Scienceand Practice of Pediatric Cardiology. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1998:1257.

  32. Luciani GB, Barozzi L, Tomezzoli A, et al. Bicuspid aortic valve disease and pulmonary autograft root dilatation after the Ross procedure: a clinicopathologic study. J Thorac Cardiovasc Surg. 2001;122:74-9. [Medline].

  33. Luciani GB, Favaro A, Casali G, et al. Reoperations for aortic aneurysm after the Ross procedure. J Heart Valve Dis. 2005;14:766-72. [Medline].

  34. Luciani GB, Favaro A, Casali G, et al. Ross operation in the young: a ten-year experience. Ann Thorac Surg. 2005;80:2271-7. [Medline].

  35. Lupinetti FM, Duncan BW, Lewin M, et al. Comparison of autograft and allograft aortic valve replacement in children. J Thorac Cardiovasc Surg. 2003;126:240-6. [Medline].

  36. Matsuki O, Okita Y, Almeida RS, et al. Two decades' experience with aortic valve replacement with pulmonary autograft. J Thorac Cardiovasc Surg. Apr 1988;95(4):705-11. [Medline].

  37. Muresian H. The Ross procedure: new insights into the surgical anatomy. Ann Thorac Surg. 2006;81:495-501. [Medline].

  38. Nordmeyer J, Coats L, Bonhoeffer P. Current experience with percutaneous pulmonary valve implantation. Semin Thorac Cardiovasc Surg. Summer 2006;18(2):122-5. [Medline].

  39. Ohye RG, Gomez CA, Ohye BJ, et al. The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function. Ann Thorac Surg. 2001;72:823-30. [Medline].

  40. Oswalt JD, Dewan SJ, Mueller MC, Nelson S. Highlights of a ten-year experience with the Ross procedure. Ann Thorac Surg. 2001;71:S332-S335. [Medline].

  41. Oury JH, Maxwell M. Cox JL, Sundt TM III, eds. An appraisal of the Ross procedure: goals and technical guidelines. In: . Operative Techniques in Cardiac & Thoracic Surgery: A Comparative Atlas. Vol 2. Philadelphia, PA: WB Saunders; 1997:289.

  42. Raja SG, Pozzi M. Growth of pulmonary autograft after Ross operation in pediatric patients. Asian Cardiovasc Thorac Ann. 2004;12:285-90. [Medline].

  43. Raja SG, Pozzi M. Ross operation in children and young adults: the Alder Hey case series. BMC Cardiovasc Disord. 2004;4:3. [Medline].

  44. Reddy VM, McElhinney DB, Phoon CK, et al. Geometric mismatch of pulmonary and aortic anuli in children undergoing the Ross procedure: implications for surgical management and autograft valve function. J Thorac Cardiovasc Surg. 1998;115:1255-62. [Medline].

  45. Ross D, Jackson M, Davies J. Pulmonary autograft aortic valve replacement: long-term results. J Card Surg. Dec 1991;6(4 Suppl):529-33. [Medline].

  46. Ross D, Jackson M, Davies J. The pulmonary autograft--a permanent aortic valve. Eur J Cardiothorac Surg. 1992;6(3):113-6; discussion 117. [Medline].

  47. Rubay JE, Raphael D, Sluysmans T, et al. Aortic valve replacement with allograft/autograft: subcoronary versus intraluminal cylinder or root. Ann Thorac Surg. 1995;60:S78-S82. [Medline].

  48. Ruzmetov M, Vijay P, Rodefeld MD, et al. Evolution of aortic valve replacement in children: A single center experience. Int J Cardiol. Dec 21 2005;[Medline].

  49. Slater M, Shen I, Welke K, et al. Modification to the Ross procedure to prevent autograft dilatation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005;181-4. [Medline].

  50. Starnes VA, Luciani GB, Wells WJ, Allen RB, Lewis AB. Aortic root replacement with the pulmonary autograft in children with complex left heart obstruction. Ann Thorac Surg. Aug 1996;62(2):442-8; discussion 448-9. [Medline].

  51. Starnes VA, Luciani GB, Wells WJ, et al. Aortic root replacement with the pulmonary autograft in children with complex left heart obstruction. Ann Thorac Surg. Aug 1996;62(2):442-8; discussion 448-9. [Medline].

  52. Sundt TM, Moon MR, Xu H. Reoperation for dilatation of the pulmonary autograft after the Ross procedure. J Thorac Cardiovasc Surg. 2001;122:1249-52. [Medline].

  53. Svensson G, Aljassim O, Svensson SE, et al. Anatomical mismatch of the pulmonary autograft in the aortic root may be the cause of early aortic insufficiency after the Ross procedure. Eur J Cardiothorac Surg. 2002;21:1049-54. [Medline].

  54. Takkenberg JJ, Dossche KM, Hazekamp MG, et al. Report of the Dutch experience with the Ross procedure in 343 patients. Eur J Cardiothorac Surg. 2002;22:70-7. [Medline].

  55. Takkenberg JJ, van Herwerden LA, Galema TW, et al. Serial echocardiographic assessment of neo-aortic regurgitation and root dimensions after the modified Ross procedure. J Heart Valve Dis. 2006;15:100-6. [Medline].

  56. Takkenberg JJ, Zondervan PE, van Herwerden LA. Progressive pulmonary autograft root dilatation and failure after Ross procedure. Ann Thorac Surg. 1999;67:551-3. [Medline].

  57. Turley K, Bove EL, Amato JJ, et al. Neonatal aortic stenosis. J Thorac Cardiovasc Surg. Apr 1990;99(4):679-83; discussion 683-4. [Medline].

  58. Tweddell JS, Pelech AN, Frommelt PC, Jaquiss RD, Hoffman GM, Mussatto KA. Complex aortic valve repair as a durable and effective alternative to valve replacement in children with aortic valve disease. J Thorac Cardiovasc Surg. Mar 2005;129(3):551-8. [Medline].

  59. Vida VL, Rubino M, Bottio T, et al. Performance of the pulmonary autograft in four infants after the Ross procedure. Pediatr Cardiol. 2005;26:797-800. [Medline].

  60. Williams IA, Quaegebeur JM, Hsu DT, et al. Ross procedure in infants and toddlers followed into childhood. Circulation. 2005;112:I390-5. [Medline].

  61. Zeevi B, Keane JF, Castaneda AR, et al. Neonatal critical valvar aortic stenosis. A comparison of surgical and balloon dilation therapy. Circulation. Oct 1989;80(4):831-9. [Medline].

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Further Reading

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Keywords

aortic valve disease, AVR, aortic valve replacement, aortic-valve replacement, aortic valve repair, aortic valve disease in children, Ross operation, Ross procedure, Ross-Konno procedure, progressive stenosis, ventricular outflow tract obstruction, balloon aortic valvuloplasty, rheumatic aortic valve disease, aortic insufficiency, aortic valve endocarditis, pericardial leaflet extension, commissural reconstruction, annuloplasty, sinus of Valsalva reduction, sinotubular junction remodeling, complete leaflet replacement, Marfan syndrome, Ehlers-Danlos syndrome, systemic lupus erythematosus, ankylosing spondylitis, Reiter disease

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Contributor Information and Disclosures

Author

Bahaaldin Alsoufi, MD, Consulting Surgeon, Department of Pediatric Surgery, King Faisal Heart Institute, King Faisal Specialist Hospital and Research Centre
Bahaaldin Alsoufi, MD is a member of the following medical societies: American College of Surgeons, Royal College of Physicians and Surgeons of Canada, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher A Caldarone, MD, Associate Professor, Department of Surgery, The Hospital for Sick Children, University of Toronto
Christopher A Caldarone, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Gregory B Dalshaug, MD, Assistant Professor, Division of Cardiovascular Surgery, Royal University Hospital
Gregory B Dalshaug, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Canadian Medical Association, Iowa Medical Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Daniel S Schwartz, MD, FACS, Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital
Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

John Myers, MD, Director, Pediatric and Congenital Cardiovascular Surgery, Departments of Surgery and Pediatrics, Professor, Penn State Children's Hospital, Milton S Hershey Medical Center
John Myers, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, Congenital Heart Surgeons Society, Pennsylvania Medical Society, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

John Kupferschmid, MD, Director of Congenital Heart Surgery, Department of Surgery, Methodist Children's Hospital at San Antonio
John Kupferschmid, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, Society of Thoracic Surgeons, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

 
 
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