The original Ross procedure has evolved and changed somewhat over time. Initially the entire autograft was implanted in the same position as the excised native aortic valve. However, due to surgical difficulties and complications, the procedure has migrated to replacement of the entire root of the aorta with reimplantation of the coronary arteries. This latter approach involves more surgical suture lines, but has been conclusively demonstrated to more reproducible results with the least complications. For the purposes of this presentation, the root replacement technique, now the most common variant of the Ross, will be illustrated in detail.
To perform the operation, the heart muscle (i.e. myocardium) must be carefully protected against ischemia (deprivation of oxygen or nutrients) during the entire operation. The surgeon must pay close attention to myocardial preservation, cooling, and complete relaxation of the heart muscle. This is done with periodic infusions of a potassium bearing solution, with or without the addition of blood. Every cardiac surgeon must be familiar with myocardial preservation techniques such as this, and use them meticulously in the long and detailed Ross procedure.
The operation is performed through a vertical incision which divides the breastbone (or sternum). After exposure to the heart itself, the patients circulation is taken over by the heart-lung pump and the body temperature decreased to 27 degrees Centigrade. Cooling helps preserve the body tissues and the heart muscle during the physiologic alterations characteristic of heart-lung bypass and open heart surgery. The pumping action of the heart is suspended by infusion of a high potassium solution in the nutrient arteries to the heart (known as "coronary arteries").
Once the heart is rested and
the blood is diverted into the heart-lung machine, the aorta is opened and the patients native aortic valve can be seen directly. Pathologic changes such as stenosis,calcification, leaflet
retraction, stiffen commisural fusion and bicuspid valve architecture are inspected. At this early stage of the operation, the diseased aortic valve is removed with sharp instruments and all calcifications extracted. The remaining opening present after the removal of
the leaflets is called the annulus. It is this ring of tough fibrous tissue into which any replacement valve must be sewn. The supporting fibers of the aortic annulus are intertwined with the heart muscle of the main pumping chamber (the left ventricle, or LV). Just above the annulus lies the main coronary arteries, one supplying the left side of the heart, and another
supplying the right side of the heart. Through these 3 mm openings flow all the blood that nourishes the heart itself. If any impairment of these openings occurs during the procedure, a major heart attack can occur. One of the premier goals of the surgeon is preservation of these openings (called the coronary ostia) and the arteries they give off. The surgical anatomy of the
coronary arteries is one of the technical hardships facing the Ross surgeon. Next, the autograft is harvested in one piece.
Removal of the pulmonary valve as a unit without harm to surrounding structures is one of the key steps in the operation. The front two-thirds of the pulmonary annulus can be quickly liberated as it is free from any surrounding structures of concern.However there are key coronary artery branches which lie just under the surface of the back wall,as seen in this illustration. The left anterior descending (LAD) is the largest and most vital of the nutrient arteries to the heart muscle. It lies just behind the pulmonary annulus. In addition, the LAD gives off one or two important branches as it traverses behind the pulmonic valve. The first septal perforator (S1) and often the second septal perforator (S2) are significant branches of the early LAD which can be located within the field of dissection. During removal of the autograft, careful surgical technique must be used along the back wall in order to avoid injury to any of these
important coronary arteries.
To begin the harvest, the pulmonary artery is divided well beyond the pulmonic valve and the quality of the PV is inspected. Although rare, any
abnormalities of the native pulmonary valve would preclude its use as an autotransplant. To proceed with the next step of harvesting, a right angled forcep is passed through the divided pulmonary artery and across the pulmonary valve. The clamp is driven through the muscle of the anterior right ventricle just below the PV. This marks the level of proximal transection.Next, this opening is expanded into a transverse incision encircling the entire base of the valve. As the back wall of the pulmonary autograft is dissected and lifted away, the surgeon must avoid carrying the dissection too deep where the coronary arteries are located. The initial back wall incision should be shallow, after which the scissor movement is immediately changed, pointing towards the patients head. Meticulous, small snips of the scissors are used to liberate the back wall of the autograft without injurying the underlying coronary arteries. If done successfully, the entire pulmonary valve, annulus, and a rim of heart muscle below the annulus is harvested in one piece. Inspection of the leaflets should confirm a natural three leaflet valve still attached to a short segment of native pulmonary artery trunk. This tissue block is the autograft that will be used to completely replace the aortic valve and root removed earlier.
At this stage of
the procedure,the autograft is sized by passing a series of measured dilators through the annulus.The same technique is used to obtain a measured diameter of the recipient aortic
annulus. It is anticipated that the native pulmonary valve is exactly the same
size as the native aortic valve, thus eliminating any sizing problems. This ideal match is not always the case however. Pathologic entities in the patients be
associated with either enlargement or restriction of the native aortic valve
and annulus. Surgical experience has now shown that the most successful
technique for handling as size mismatch is to modify the aortic annulus,
while leaving the pulmonary autograft alone. Removal of certain areas of the aortic annulus, splitting of the annulus, patching, and other techniques can suitably enlarge the total diameter and circumference permitting the surgeon the opportunity to insert the pulmonary autograft without distortion.One of the advantages of the total root replacement variation of the Ross procedure is the flexibility possible in resizing the aortic annulus which then permits a nearly exact match with the donor graft. The autograft cab then transplanted as a intact unit without any distortion.
The aortic annulus now needs to be prepared for the reconstruction. First, the main
coronary arteries are mobilized and removed from the remnant of the aortic root. The left
main coronary artery (LM) and the right main coronary artery (RM) are separated
from the aortic wall leaving a 5 mm or greater rim of surrounding tissue. This rim
creates an island of tissue that makes it easy and safe to sew onto the autograft. Additional prepatory steps may be needed as well. When the native aortic annulus is too large, a reduction operation should be performed. There are a number of possible methods, all designed to reduce the overall aortic root circumference. In such cases, it is paramount to reinforce the aortic root so that late dilatation followed by valvular regurgitation does not occur. To support the annulus, a
strip of Teflon felt is placed around the aortic root and fastened in place with
tacking sutures. Then the autograft is anchored to this opening with
interrupted sutures. In children, it is important to anticipate growth of the
entire reconstruction. In fact, this is one of the true advantages of performing
the Ross procedure for children with aortic valve disease. In this situation, an
external bolster of felt is not used. Interrupted sutures are placed as shown,and the graft will grow as the child grows. If the aortic root is narrowed,then removal of the commissural tips will allow expansion and enlargement.Tailoring the aortic root to the pulmonary autograft preserves the natural shape of the pulmonary valve and reduces the likelihood of distortion of the
autograft during creation of the complex sutured anastomosis.
After preparing the aortic root, the native aortic annulus is rimmed with sutures (either polypropylene or polyester). The sutures are stitched up through the muscle bundles underneath the pulmonary autograft which is then seated inside the native aortic annulus. One way to expedite this anastomosis is to invert the autorgraft,place it into the ventricle, and sew the two rims of tissue together. After completion, the autograft is everted, and the normal
anatomical configuration restored.
After tying down the sutures, the graft becomes secured to the aortic annulus. Additional sutures may be used to guard against bleeding at the
juncture between the graft and the heart. In this illustration, The orientation
of the autograft is nearly identical to its front-back position before
harvesting.
The coronary arteries now need to be reimplanted in an anatomical fashion, free of
any kinking,twisting, or tension. Side holes are made in the autograft which
correspond to the ideal anatomical locations of the coronary arteries. Then the coronary buttons are sewn to the edges of these side holes, starting with the more deeply placed
left coronary artery. Some surgeons will then sew the top edge of the
autograft to the cut edge of the native aorta, reconstituting the aortic channel
as a single tube. Then the aorta is transiently distended with blood, and a locator mark placed where the right coronary button should be reimplanted.
After this, the side hole for the right coronary is made, and the anastomosis
with the button created. This completes the implantation of the pulmonary
autograft in the aortic position. Now the surgeon must reconstruct the gap
left by the harvesting of the pulmonary valve.
During the autograft implantation, the operating room staff thaws out a human cadaver graft (i.e. pulmonary homograft) for eventual replacement of the patients missing pulmonary valve. This graft usually arrives from a
supplier after harvesting, sterilization, freeze-drying, and storage in liquid
nitrogen. The preservation of human cadaver (homograft) heart valves and
other donated organs is a separate and detailed technology, outside the
scope of this presentation. However, the availability freeze-dried human
tissues makes it possible for surgeons in many areas of the country to
perform the pulmonary reconnection knowing that a suitable replacement is
available when needed. 
The thawed human cadaver graft is brought into the surgical field. The end of the graft is trimmed and sewn to the
transected end of the native pulmonary artery. The base of the cadaver graft (i.e. homograft) is sewn to the right
heart exactly where the autograft was removed. It is important to religiously protect the coronary artery branches laying just underneath the heart
muscle of the back wall when placing the running suture to create this final
anastomosis. Once completed, the gap created by the donation of the native
PV has been closed, and the operation is technically completed. The
remainder of the surgeons tasks are resuscitation of the heart beat, removal
from the heart-lung bypass machine, control of bleeding, and closure of the
chest.
In most Ross procedures, the result can be immediately assessed in the operating room using specialized sonar examinations, a technique called transesophageal echocardiography. The presence of leakage, blockage, kinking, or other possible distortions of the implanted autograft (or even cadaver pulmonary replacement) can be visualized, and appropriate steps taken if necessary. Once the physiology and anatomy of the result has been confirmed and the patient stabilized, the incision is closed and the patient returned to the intensive care unit.
The above slide show demonstrate series of actual oprative picture of ROSS PROCEDURE this is extreme extention of AORTIC VALVE replcement and has great potential for younger individuals.(I WILL BE DEVOTING MORE TIME TO THIS SUBJECT AND PROVIDE MORE INFORMATION in near future).