Successful Repair of a Bicuspid Pulmonary Autograft Valve Causing Early Insufficiency After a Ross Procedure

The Ross Procedure in Adolescence and Beyond: Are There Still Contraindications?

The Ross procedure is an excellent operation to treat children and adults with aortic valve disease. Compared to prosthetic aortic valve replacement, it provides important clinical benefits in terms of survival, hemodynamics, freedom from valve-related complications, and durability, especially in women of childbearing age. However, the Ross procedure is a longer and technically more challenging operation. As a result, the choice of procedure should be driven by patient anatomy and clinical characteristics. This highlights the importance of concentrating care in Ross reference centers where surgical expertise and experience are present to ensure patient safety and long-term effectiveness of the operation. This manuscript reviews the major and relative contraindications to the Ross procedure.

Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts

The Ross, or pulmonary autograft, procedure presents a fascinating mechanobiological scenario. Due to the common embryological origin of the aortic and pulmonary root, the conotruncus, several authors have hypothesized that a pulmonary autograft has the innate potential to remodel into an aortic phenotype once exposed to systemic conditions. Most of our understanding of pulmonary autograft mechanobiology stems from the remodeling observed in the arterial wall, rather than the valve, simply because there have been many opportunities to study the walls of dilated autografts explanted at reoperation. While previous histological studies provided important clues on autograft adaptation, a comprehensive understanding of its determinants and underlying mechanisms is needed so that the Ross procedure can become a widely accepted aortic valve substitute in select patients. It is clear that protecting the autograft during the early adaptation phase is crucial to avoid initiating a sequence of pathological remodeling. External support in the freestanding Ross procedure should aim to prevent dilatation while simultaneously promoting remodeling, rather than preventing dilatation at the cost of vascular atrophy. To define the optimal mechanical properties and geometry for external support, the ideal conditions for autograft remodeling and the timeline of mechanical adaptation must be determined. We aimed to rigorously review pulmonary autograft remodeling after the Ross procedure. Starting from the developmental, microstructural and biomechanical differences between the pulmonary artery and aorta, we review autograft mechanobiology in relation to distinct clinical failure mechanisms while aiming to identify unmet clinical needs, gaps in current knowledge and areas for further research. By correlating clinical and experimental observations of autograft remodeling with established principles in cardiovascular mechanobiology, we aim to present an up-to-date overview of all factors involved in extracellular matrix remodeling, their interactions and potential underlying molecular mechanisms.

Ventricular Septal Defect Jeopardizes the Autograft in a Ross Operation

The Ross operation is the gold standard for aortic valve replacement in young patients because it is a durable and anticoagulation-free alternative to mechanical aortic valve replacement. Careful assessment of the pulmonary valve is critical because it should become a durable neoaortic valve. Here we report the case of a patient in whom the pulmonary autograft was jeopardized by a large, doubly committed ventricular septal defect that did not offer sufficient autologous tissue for the proximal suture line. Surgeons should be aware that patients presenting with Laubry-Pezzi syndrome can be poor or challenging candidates for Ross procedures.

Repair of a Quadricuspid Autograft

Aortic valve replacement using a pulmonary autograft is an accepted option in children and young patients. The use of a pulmonary valve with congenital anomaly as autograft is controversial. We describe a case in which a quadricuspid pulmonary valve was used as an autograft in childhood. The patient presented with severe regurgitation 13 years later. Repair was performed with stabilization of the root and cusp prolapse correction, leading to normalized valve function. Despite concerns over the long-term durability of an anomalous pulmonary valve as autograft, good mid to long-term results can be achieved.