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The challenge of the Reimplantation Technique after a Ross Procedure

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THE CHALLENGE OF THE REIMPLANTATION TECHNIQUE AFTER A ROSS PROCEDURE

S. Solari, L. De Kerchove, G. El Khoury

St. Luc' s Hospital, Catholic Univeristy of Louvain, Brussels, Belgium

Patient Demographics

DAV, male ,58 years old, Caucasian 

Relevant History

The patient underwent a Ross procedure for a stenotic bicuspid aortic valve in 2001.The postoperative recovery was favourable, only complicated by a transitory atrial fibrillation event. The patient was discharged 9 days after in good clinical condition. No autograft or homograft regurgitations were described in the postoperative echo.

At the April 2016 follow up, a severe aortic autograft regurgitation due to a left cusp prolapse and a dilatation of the Valsalva sinus was held liable for a pattern of dilated cardiomyopathy with a left ventricular ejection fraction mildly compromised. No abnormalities were detected in the pulmonary homograft. The coronary angiogram also showed a significative LAD stenosis. Despite this, the patient was completely asymptomatic.

Pre-Operative Plan

Considering the echographic picture, the surgical indication was clear, even if this re-intervention had a far from negligible risk. Moreover, taking into consideration the young age and the characteristic of the autograft regurgitation it was quite obvious that the best option for the patient was a valve sparing. Nevertheless, the high complexity of the redo could have obliged us to change our mind and replace the autograft.

Discussion

Since our purpose was to preserve both the autograft and the homograft, the tissues dissection had turned out to be a real challenge, especially regarding the aorto-ventricular junction where the pericardial ring placed during the first intervention had heavily calcified. After having carefully separated the autograft from the homograft and after having totally released the aorto-ventricular junction, the autograft was reimplanted in a Valsava graft 32 mm. A dacron patch coming from the tubular graft was used to reinforce the muscular septum damaged by decalcification. A triangular resection of the left coronary cusp and a central plication of the non-coronary and right cusp were also performed, and a aorto-coronary bypass graft (LIMA-LAD) completed the operation. During the postoperative period the patient just experienced transitory atrial fibrillation episode and mild acute renal failure. He has been discharged 9 days after the operation with no autograft regurgitation at the echo assessment.

Surgical features

A   Surgical presentation of the autograft. The quality of the valve is quite good, the cusps are soft and mobile. We can easily see the left coronary cusp prolaps.

B    It is to notice that, during the first intervention, a pericardial patch was used in order to reinforce all the proximal anastomosis of the autograft.  As  we decided to repair and reimplant the autograft, it’s MANDATORY to remove  the calcified pericardial band to set the ventricuo-aortic junction (VAJ) free.

C    During the dissection an injury of the muscular septum occurred .To avoid any interventricular septum defect, all the VAJ corresponding to the muscular septum  was reinforced with a dacron patch coming from the valsalva graft.

D   After the autograft was reimplanted in the dacron valsalva graft,  a triangular resection of the left coronary cusp and a central plication of the non-coronary and right  cusp were also performed to recreate the cusps coaptation with an excellent result.

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