Pulmonary reconstruction in the ross procedure: Combined autologous aortic and polytetrafluoroethylene valve

Abstract

Aortic root replacement with the pulmonary autograft is a valuable technique especially in children with the left ventricular outflow obstruction or a dilated aortic anulus, because it avoids use of a prosthetic valve and anticoagulation therapy. However, problems with durability and growth potential of the pulmonary autografts in the aortic position have been reported. 1 The best material for reconstructing the right ventricular outflow tract (RVOT) also remains controversial. We describe a technique performed concomitantly with the Ross procedure, in which the RVOT was reconstructed with a tricuspid valve made of the autologous aortic noncoronary cusp and a bicuspid valve made of expanded polytetrafluoroethylene (ePTFE). The patient was an 8-year-old girl, weighing 23 kg, in New York Heart Association functional class II. The echocardiogram showed that the aortic valve had 3 cusps: a large mobile noncoronary cusp and small restrictive right and left cusps. All commissures were fused. Cardiac catheterization and cineangiocardiogram showed a pressure gradient of 80 mm Hg between the left ventricle and ascending aorta and moderate aortic regurgitation. The aortic annular diameter was 19 mm (144% of normal value); the pulmonary annular diameter was 14 mm (106% of the normal aortic annular value). Preoperatively, 400 mL of autologous whole blood was drawn and stored for postoperative transfusions, and recombinant epoetin alfa (Kirin Permacology, Tokyo, Japan) was administered. Through a median sternotomy, moderate hypothermic cardiopulmonary bypass (28°C) was established. With the heart beating, the anterior and lateral aspects of the pulmonary artery were excised from the RVOT. The posterior aspect was excised after aortic crossclamping and administration of cold crystalloid cardioplegic solution, taking care to avoid the septal perforator coronary artery. The excised pulmonary autograft was preserved in cold saline solution. The ascending aorta was transected 5 mm above the sinotubular junction. The left and right coronary ostia were detached along the adjacent aortic wall. The right and left coronary cusps were hypoplastic and tightly adherent to a subvalvular fibrous ridge; neither of the cusps was mobile. The free edge of the noncoronary cusp was slightly hypertrophied but sufficiently mobile. This cusp was harvested along with the adjacent aortic wall. The right side of the aortic fibrous ring of the noncoronary cusp was preserved to avoid injury to the atrioventricular conduct