Aortic Conduit Research Articles

The Ross Operation Over 55 Years Later: Comparing Surgical Techniques and Outcomes.

The Ross procedure is often considered the best option for a small group of patients. Some critics argue that harvesting the pulmonary artery again can cause problems, such as exposing the native pulmonary autograft to systemic pressures and requiring further intervention. However, the pulmonary autograft is a living tissue that can adjust to growing conditions and undergo remodelling. The pathophysiology of living tissue, harvesting techniques, indications for use of pulmonary autograft in aortic valve disease, contraindications, and variations of pulmonary autograft as an aortic conduit are discussed in this seminar. Following recent updates from high-volume centres, the indications, contraindications, techniques, and variations of pulmonary autograft as an aortic conduit and, in the absence of substantial well-designed randomised controlled trials, areas where the Ross procedure needs to be reaffirmed as part of the surgical armamentarium are also discussed. Furthermore, increasing evidence suggests that the Ross procedure produces better long-term results than traditional aortic valve replacement in young and middle-aged adults. To enable cardiologists and surgeons to make appropriate decisions for their patients with aortic valve disease, the author provides a complete review of the most recent published studies on the Ross procedure.

Clinical relevance of aortic conduit and reservoir function

BackgroundAortic conduit and reservoir functions can be directly measured by four-dimensional flow (4D flow) cardiovascular magnetic resonance (CMR).MethodsTwenty healthy controls (10 young and 10 age-gender-matched old controls) and 20 patients...

Endovascular Treatment of a Multi-visceral Aortic Conduit Blowout With Parallel Stent Grafts and Coils.

Multi-visceral transplantation (MVT) is a complex surgical procedure involving the transplantation of multiple abdominal organs as a single unit, typically used as bailout treatment of patients with devastating abdominal pathologies. Due to the complexity of the procedure, major and even life-threatening complications can happen. Vascular complications, including anastomotic breakdowns or pseudoaneurysms due to infections, can be universally lethal. Open surgical repair is often not an option due to the hostile operative field. We report a case of endovascular salvage of multi-visceral aortic conduit blowout utilizing parallel stent grafts and coils without sacrifice of the transplanted viscera. This combination can successfully control bleeding and maintain graft perfusion in this rare but devastating complication.

Abstract 11589: Late Complications After Interrupted Aortic Arch Repair

Description of Case: A 38-year-old man with known type B interrupted aortic arch (IAA), bicuspid aortic valve, and a complex surgical history (including IAA repair with an ascending-descending aortic conduit, later conduit graft revision, and left pulmonary artery [LPA] stent) presented after many years of loss to follow-up and was found to have hypertensive urgency. Echocardiogram showed turbulent flow in the proximal descending aorta concerning for arch obstruction. Computed tomography angiography (CTA) (Fig. 1 A–C) showed: narrowed proximal graft anastomosis, dilation of the aortic root and ascending aorta, a large pseudoaneurysm arising from the distal graft anastomosis, and LPA stenosis due to compression from the descending aorta. Following improved hypertension, the patient underwent placement of a left carotid-subclavian bypass graft followed by thoracic endovascular aortic repair (TEVAR) with an endograft positioned across the distal aortic jump graft suture line. CTA one month postoperatively (Fig. 1 D–F) confirmed exclusion of the pseudoaneurysm. Discussion: Type B IAA is considered the most common subtype of IAA among cases diagnosed in infancy, though recent data regarding IAA epidemiology are scarce. IAA is associated with other congenital abnormalities, such as ventricular septal defect (VSD), LV outflow tract abnormalities, and 22q11 deletion syndrome. Additional surgical aortic arch procedures in these patients are not uncommon, perhaps especially among patients who required reintervention for LV outflow tract obstruction. While most studies examining long-term outcomes after IAA repair have not commented specifically on late risk of aneurysm or pseudoaneurysm, such findings have been described in the literature. Additionally, use of polytetrafluoroethylene material in arch repair and arch repair by a method other than direct anastomosis—such as were seen in our patient—have been observed to be risk factors for late reintervention.

Restoration of flow in the aorta: a novel therapeutic target in aortic valve intervention.

Aortic blood flow patterns are closely linked to the morphology and function of the left ventricle, aortic valve and aorta. These flow patterns demonstrate the exceptional adaptability of the cardiovascular system to maintain blood circulation under a broad range of haemodynamic workloads and can be altered in various pathophysiological states. For instance, normal ascending aortic systolic flow is predominantly laminar, whereas abnormal aortic systolic flow is associated with increased eccentricity, vorticity and flow reversal. These flow abnormalities result in reduced aortic conduit function and increased energy loss in the cardiovascular system. Emerging evidence details the association of these flow patterns with loss of aortic compliance, which leads to adverse left ventricular remodelling, poor tissue perfusion, and an increased risk of morbidity and death. In this Perspective article, we review the evidence for the link between aortic flow-related abnormalities and cardiovascular disease and how these changes in aortic flow patterns are emerging as a therapeutic target for aortic valve intervention in first-in-human studies.

Impact of different in vitro models on functional performance of the self-expanding transcatheter heart valve.

Transcatheter heart valves (THVs) are investigated according to International Organization for Standardization requirements using in vitro heart simulators to evaluate hydrodynamic performance. In contrast to surgical valves, a THV's performance heavily depends on the configuration and shape of the aortic anulus. In International Organization for Standardization regulations, there is no detailed definition for the construction of a compartment in which a THV has to be tested. Therefore, the aim of this in vitro study was to compare different in vitro models for functional testing of THVs. Porcine aortic conduits (23-mm diameter) were implanted in Dacron prostheses and calcified with double-distilled water and calcification buffer at 37°C over 83 million cycles in a Hi-Cycler (durability testing) mimicking nearly 3 patient-years. Hydrodynamic testing of Evolut PRO 26 mm was performed within 3 models (plexiglass, native conduit and calcified conduit; all 23-mm diameter) at a frequency of 64 bpm and different stroke volumes (55-105 ml). Calcified conduits showed significantly higher mean pressure gradients (MPG) and lower effective orifice areas (EOA) in comparison to native conduits (without THV; P < 0.001). EOA and MPG of Evolut PRO differed depending on the model tested. Calcified conduits resulted in the lowest EOA and highest MPG of the THV compared to plexiglass and the native conduit. Full expansion of the THV was least impaired in the native conduit, while lowest geometric orifice area, lowest minimal internal diameter and highest pin-wheeling index of Evolut PRO were seen in the calcified conduit. Full expansion and functional performance of the Evolut PRO THV depends on the configuration of the testing compartment in an in vitro setting.

Ross procedure versus pulmonary homograft versus mechanical valve versus bioprosthetic valve versus Ozaki procedure for surgical aortic valve replacement: a frequentist network meta-analysis

BackgroundThere has been a resurgence in interest regarding the Ross procedure due to recent publications detailing positive long-term outcomes. Conversely, surgical aortic valve replacement (SAVR) with a pulmonary homograft (PH), mechanical (MV), bioprosthetic (BV), or the Ozaki procedure each has its own technical advantages and disadvantages. Therefore, we performed a network meta-analysis (NMA) comparing other alternatives to Ross procedure.MethodsMedical databases were comprehensively searched for studies comparing the Ross procedure with AVR using a PH, MV, BV, or the Ozaki procedure. Outcomes were pooled as risk ratios (RR) with their 95% confidence intervals (95% CI).ResultsA total of 7816 patients were pooled for our NMA from 24 studies. Compared to Ross procedure, both BV and MV were associated with significantly higher rates of 30-day mortality of RR (2.37, 95% CI 1.20–4.67) and (1.88 95% CI 1.04–3.40), respectively, with no significant difference regarding PH or Ozaki. However, only MV was associated with a higher risk of 30-day stroke (RR 8.42, 95% CI 1.57–45.23) with no significant difference in the other alternatives, as well as 30-day MI which showed no significant differences between any of the aortic conduits compared to the Ross procedure. Regarding 30-day major bleeding, MV was associated with a higher when compared to the Ross procedure RR (4.58, 95% CI 1.94–10.85), PH was associated with a lower risk of major bleeding with RR (0.35, 95% CI 0.17–0.71), and BV showed no significant difference. With a mean follow-up duration of 8.5 years compared to the Ross procedure, BV, PH, and MV were associated with a higher risk of long-term mortality with RR (1.89, 95% CI 1.38–2.58), (1.38, 95% CI 1.0–1.87), and (1.94, 95% CI 1.52–2.47), respectively, with the Ozaki procedure showed no significant difference. Regarding long-term stroke—with a mean of 6.3-year follow-up duration—there were no significant differences between any of the aortic conduits compared to the Ross procedure. Nevertheless, long-term need for reintervention—with a mean follow-up duration of 17.5 years—was significant of higher risk with both BV and PH with RR (3.28, 95% CI 1.21–8.84) and (2.42, 95% CI 1.05–5.58), respectively, compared to Ross procedure with MV and Ozaki having no significant difference.ConclusionsThe Ross procedure is a viable treatment option for patients undergoing SAVR, showing promising outcomes at short- and long-term follow-ups.

Degeneration of biological heart valve grafts in a rat model of superoxide dismutase-3 deficiency.

While oxidative stress is known as key element in the pathogenesis of atherosclerosis and calcific aortic valve disease, its role in the degeneration of biological cardiovascular grafts has not been clarified yet. Therefore, the present study aimed to examine the impact of oxidative stress on the degeneration of biological cardiovascular allografts in a standardized chronic implantation model realized in rats exhibiting superoxide dismutase 3 deficiency (SOD3(-) ). Rats with SOD3 loss-of-function mutation (n=24) underwent infrarenal implantation of cryopreserved valved aortic conduits, while SOD3-competent recipients served as controls (n=28). After a follow-up period of 4 or 12 weeks, comparative analyses addressed degenerative processes, hemodynamics, and evaluation of the oxidative stress model. SOD3(-) rats presented decreased circulating SOD activity (p=.0079). After 12 weeks, 58% of the implant valves in SOD3(-) rats showed regurgitation (vs. 31% in controls, p=.2377). Intima hyperplasia and chondro-osteogenic transformation contributed to progressive graft calcification (p=.0024). At 12 weeks, hydroxyapatite deposition (p=.0198) and the gene expression of runt-related transcription factor-2 (Runx2) (p=.0093) were significantly enhanced in group SOD3(-) . This study provides the first in vivo evidence that impaired systemic antioxidant activity contributes to biological cardiovascular graft degeneration.

Feasibility of Low-Seated Composite Aortic Conduit for Surgical Treatment of Prosthetic Valve Endocarditis: A Case Report

Background: A 49-year-old male presented with a delayed diagnosis of infective endocarditis leading to extensive intracardiac destruction. Such cases present technical challenges to operative debridement as crucial anchoring points for replacement conduits are compromised. Case Presentation: Our patient presented at age 49 with nausea, lethargy, and diarrhea 2 weeks after recent travel. His prior history included bioprosthetic valve replacement for a bicuspid aortic valve. The patient was first given a trial of antimicrobials for a suspected UTI. Subsequently, he was admitted briefly to an outside hospital for a “cardiac work-up,” which returned negative. The patient sought care for the third time, during which he developed unstable supraventricular tachycardia, prompting echocardiography 16 days following the onset of symptoms. Echocardiography demonstrated a 6 cm abscess cavity invading the interventricular septum with a fistula into the left ventricular outflow tract, multiple ventricular septal defects (VSD), and suspected fistulae into the right ventricular outflow tract. The patient was treated with valve explant and extensive debridement. A valved-conduit for the aorta could not be sewn to the aortic annulus in the usual fashion due to destruction and debridement of the annulus, so a neo-annulus was created using the anterior leaflet of the mitral valve and the left ventricular outflow tract of the heart below the level of the VSDs. A mechanical-valved conduit was implanted onto the neo-annulus. A pacemaker was subsequently implanted. Conclusion: In patients with extensive intracardiac destruction with the compromise of the aortic annulus due to infective endocarditis, a low-seated, mechanical-valved conduit implanted directly to the aorto-mitral curtain and left ventricular outflow tract should be considered a novel, durable reconstructive option that allows complete debridement of infected tissues.

Evaluation of muscle atrophy after sciatic nerve defect repair – experimental model

Peripheral nerve injuries are one of the most important causes for disability generating considerable costs around the world. Appropriate assessment of the extent of peripheral nerve lesions and the choice of the right therapeutic protocol remain some of the biggest challenges. Non-invasive neuroimaging approaches are suitable in managing peripheral nerve repairs, providing in the same time accuracy details in structural neural detection, with minimal discomfort at a low cost. Medical imaging technology development has led to progress in examination of peripheral nervous system, using a series of tools and methods, such as: ultrasonography (US), positron emission tomography (PET), magnetic resonance imaging (MRI) and magnetic diffusion tensor imaging (DTI). In this study, we evaluated the regeneration process in Wistar rats after sciatic nerve defects repair with 4 different techniques (i.e. nerve graft, rat aorta used as a nerve conduit, rat aorta filled with platelet rich plasma (PRP) and rat aorta filled with stem cells) by using MRI investigation alongside the clinical evaluation. Our results showed that among the 4 batches, the PRP batch had the best results in muscle atrophy condition (both on MRI scan and on gastrocnemius index); on the second place the stem cell batch, then the nerve graft batch and finally the aortic conduit batch. MRI proved to be a reliable non-invasive monitoring method and showed good result in correlation with the footprint test (sciatic functional index) and the gastrocnemius index

Conformational changes of exogenous deposited fibronectin on decellularized aortic conduits after implantation

Fibronectin is an abundant and ubiquitous extracellular matrix component that regulates a wide range of cell functions by directly interacting with cell surface integrin receptors. In a prior study, we observed that fibronectin can accelerate the autologous cellular repopulation of implanted decellularized grafts, enhancing their adhesion capacity and biocompatibility, through fibronectin fibrillogenesis. The supportive effect of deposited fibronectin was shown to be dissimilar in different regions of implanted decellularized grafts. This led us to question whether there is any difference in conformation of fibronectin deposited on the luminal and adventitial surfaces of decellularized aortic conduits after implantation. In this study, we doubly labelled fibronectin with a fluorescent resonance energy transfer (FRET) pair and use this to analyse differences in conformational changes of adsorbed fibronectin at different sites of the decellularized aortic conduits.

Unlocking the Non-invasive Assessment of Conduit and Reservoir Function in the Aorta

Aortic surgeries in congenital conditions, such as hypoplastic left heart syndrome (HLHS), aim to restore and maintain the conduit and reservoir functions of the aorta. We proposed a method to assess these two functions based on 4D flow MRI, and we applied it to study the aorta in pre-Fontan HLHS. Ten pre-Fontan HLHS patients and six age-matched controls were studied to derive the advective pressure difference and viscous dissipation for conduit function, and pulse wave velocity and elastic modulus for reservoir function. The reconstructed neo-aorta in HLHS subjects achieved a good conduit function at a cost of an impaired reservoir function (69.7% increase of elastic modulus). The native descending HLHS aorta displayed enhanced reservoir (elastic modulus being 18.4% smaller) but impaired conduit function (three-fold increase in peak advection). A non-invasive and comprehensive assessment of aortic conduit and reservoir functions is feasible and has potentially clinical relevance in congenital vascular conditions.Graphical abstract

Multi-Branched Thoracoabdominal Endovascular Aortic Repair With Branch Access Through a Left Thoracotomy and Descending Thoracic Aortic Conduit: A Novel and Effective Alternative Access

Purpose: To demonstrate an alternative access to perform directional branch catheterization during complex endovascular aortic repair. Technique: Urgent endovascular aortic repair was indicated to treat a symptomatic post dissection thoracoabdominal aneurysm with large infrarenal dilatation with an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, IN, USA). Traditional proximal arterial accesses were not suitable due to a previous aortic arch endograft. A novel approach was performed through a left postero-lateral thoracotomy, isolation of the descending thoracic aorta and anastomosed a polyester graft conduit to allow sheaths passage to the thoracoabdominal aorta with subsequently directional branch catheterization. Conclusion: The descending thoracic aortic conduit technique is an effective alternative for directional branch catheterization and should be considered whenever traditional proximal arterial accesses are not suitable and other endografts configurations not considered due to anatomic limitations.

Echocardiographic and Computed-tomographic Evaluation of the Fate of Bovine Pericardial Patch as a Pericardial Substitute in Bentall’s Procedure: Twenty-year’ Results

Objective: The study was designed to ascertain the influence of usage of bovine pericardial patch in patients undergoing Bentall’s procedure with respect to reexploration for bleeding, mediastinal infection, avoidance of conduit adhesions, late development of pericardial constriction and calcification. Materials and Methods: We reviewed 150 patients (79 males) aged between 22 to 68 years (mean±SD 49.25±12.9 years) receiving a composite aortic conduit between January 1998 to December 2020 for annuloaortic ectasia (n=100), aortic dissection (n=49), and dilated aortic root in repaired tetralogy of Fallot (n=1). Twenty-five patients had Marfan’s syndrome. Modified “button technique” was performed by interposing a glutaraldehyde treated pericardial strip at the graft coronary anastomoses, and proximal aortic conduit suturing using interlocking interrupted, pledgeted mattress suture. On completion, the pericardial cavity was reconstructed using St. Jude Medical Biocor pericardial patch. To detect evidence of pericardial constriction, survivors underwent echocardiography and computed tomography. The Kaplan-Meier curve was drawn to show the probability of survival over a period of follow-up time. Results: Seven (4.7%) patients died of cardiac-related cause, 45% had transient hemodynamic instability, 55% had low cardiac output, and 87.1% had spontaneous return of sinus rhythm. The average 12-hour postoperative drainage was 245±70 ml and there was no mediastinal infection. At a mean follow-up of 172.4 (SD± 58.9) months, the actuarial survival was 94.2±0.04% (95% CI: 88.5-96.8), and there was no pericardial constriction or calcification. Conclusion: Reconstruction of pericardial cavity using Biocor bovine pericardial patch minimizes diffuse oozing of blood, graft infection, and is not associated with later development of pericardial constriction, or calcification.

Mini-Bentall Surgery: The Right Thoracotomy Approach.

Surgeons are increasingly using the right mini-thoracotomy approach to perform aortic valve surgery. This approach has shown better results in terms of blood loss and length of hospital stay than the sternotomy approach. For selected patients requiring aortic root and ascending aorta surgery, a right mini-thoracotomy approach may prove beneficial. In our technique, we placed a 5-cm horizontal skin incision in the right second intercostal space. Femoro-femoral cardiopulmonary bypass was established. A valved aortic conduit was used for aortic root replacement. The patient’s postoperative course was uneventful, with a short hospital stay. This technique offers a minimally invasive approach to aortic root and ascending aorta surgery with easy adaptability and reduced costs.

Decellularization of the human donor aortic conduit by a new hybrid treatment in a multicomponent system with supercritical CO2 and Tween 80

Decellularization of biotissues reduces immunogenicity, promotes cell repopulation, and improves the functional parameters of biotissues, in particular reducing calcification. However, it is important to understand the impact of decellularization technologies on the characteristics of donor allografts in comparison with the functional characteristics of conventional cryopreserved implants. In this work, we tested and applied a new hybrid method of decellularization of donor human aorta in a multicomponent system with supercritical carbon dioxide and Tween 80. We compared the histological sections, structure, and mechanical strength properties of the hybrid decellurized aorta with those of the conventional cryopreserved and chemically treated donor aorta. We found that it is possible to completely remove cells and cellular components, preserve the histoarchitecture of the tissue using the hybrid treatment with scCO2/Water/EtOH/Tween 80 multicomponent system, and reorganize the collagen fibrils, which is manifested in the strengthening of the tissue (Δσ=20 ± 5%) and its increased elasticity (Δε = 20 ± 3%).

P-70: Native Jejunal Conduit for Urinary Diversion in Enbloc Liver-Intestine-Kidney Transplantation for a Patient with Irradiation Enteritis and Cystitis

Background: Recipients requiring kidney-enbloc visceral allograft often face challenges during transplantation. We report a case with a unique technique of urinary diversion in enbloc liver-intestine-kidney transplantation for irradiation enteritis and cystitis. Methods: The patient is a 65 year-old man with Crohn's disease and history of anal adenocarcinoma treated with abdominoperineal resection and adjuvant chemo- and radiotherapy. Case will be presented with pictures and/ or video. Results: The patient developed gut failure due to short gut and multiple bowel obstructions secondary to radiation enteritis. Urinary incontinence developed after irradiation caused frequent urinary tract infection leading to kidney failure. He was listed for combined liver-intestine-kidney transplantation and received en-bloc allograft from a 35 year-old male brain-dead donor. During evisceration of native organs, frozen abdomen was encountered and subtotal enterectomy leaving 30 cm of jejunum was performed. Urinary bladder was rock hard with no augmentation, unacceptable to implant the allograft ureter. Arterial inflow was established with an aortic conduit between the native and allograft infra-renal aorta. The native jejunum was transected at 10 cm and the proximal segment was connected to allograft jejunum to establish the continuity of alimentary tracts. The distal 20 cm of native jejunum was anastomosed to allograft ureter for urinary diversion Postoperative course was unremarkable with adequate urinary output and allograft functions. The patient was well rehabilitated in hospital due to lack of safe rehabilitative facilities during COVID pandemic and discharged home on post-operative day 47. Conclusion: Combined kidney and visceral transplantation in the setting of irradiated bladder requires pre-operative planning of urinary reconstruction with several options. When native intestine is available and not damaged from original disease, urinary diversion using the native jejunum is the safest option amongst others including cystoplasty and urinary diversion using allograft ileum.

The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer.

The Ross procedure has long been seen as an optimal operation for a select few. The detractors of it highlight the issue of an additional harvesting of the pulmonary artery, subjecting the native PA to systemic pressures and the need for reintervention as reasons to avoid it. However, the PA is a living tissue and capable of adapting and remodeling to growth. We therefore review the current evidence available to discuss the indications, contraindications, harvesting techniques, and modifications in a state-of-the-art narrative review of the PA as an aortic conduit. Due to the lack of substantial well-designed randomized controlled trials (RCTs), we also highlight the areas of need to reiterate the importance of the Ross procedure as part of the surgical armamentarium.

Feasibility and Outcome of Cardiovascular Surgeries Combined with Ozaki Procedure; Single Center Single Surgeon Experience

Objective: Considering aortic valve surgeries, use of prosthetic valves is associated with issues of quality, technology, availability and affordability in developing countries like Sri Lanka. In such setting, Ozaki procedure can be used to treat spectrum of aortic valve diseases, and can be combined with other cardiac surgeries. This study focused on recapitulating the current practice of Ozaki procedure combined with other cardiac surgeries. Methods: This retrospective cross sectional study was carried out from October 2019 to October 2020 at National Hospital Kandy. All patients were operated by a single surgeon. Total number of patients were 10 (6 males, 4 females) with mean age 52 years. Severe aortic stenosis 6, severe aortic regurgitation 3, combination of both 1, were assigned for Ozaki procedure and combined as follows. One patient had undergone isolated Ozaki procedure following aortic valve vegetectomy. Results: All patients were successfully weaned from CPB. Intra-operative echocardiogram showed no significant aortic or mitral regurgitation. Ejection fraction was preserved at 50 ±10%. Mean cross-clamp time for AV reconstruction only was 92 ± 18 minutes and mean length of stay on the intensive care unit was 70 ± 18 hours and hospital stay was 6 ± 1.5 days after combined procedures. No pacemaker implanted after all procedure. No reoperation done. Conclusions: In our experience, this technique can be mastered after a relatively short training period, can be used for variety of aortic valvular pathology, can combined successfully with other surgeries and even with aortic conduits. Ozaki procedure remains a very attractive strategy with excellent haemodynamics and may have the potential to overcome the structural disadvantages of prosthetic valves including use of warfarin. Combined procedure No of cases Coronary artery bypass grafting 5 Mitral valve ring annuloplasty 1 Coronary artery bypass grafting/ Mitral valve ring annuloplasty 1 Ascending aortic replacement 2

Arrow Shaped Ministernotomy Approach for the Ross Procedure

Objective: The Ross procedure is thought to have the best long-term results among aortic valve surgical interventions and has excellent hemodynamic characteristics and very low risk of valve thrombosis. We report the first four cases of arrow shaped ministernotomy Ross procedures in young adult patients. Methods: One female and three young male patients aged 42, 33, 43 and 44 respectively, with congenital complete Type 1 A bicuspid aortic valve disease received a Ross procedure via a ministernotomy approach. After a 6-7 cm skin incision, the sternum was divided in the shape of an arrow, down to the third intercostal space. The cardiopulmonary bypass was established through central cannulation. The pulmonary autograft was prepared before aortic cross-clamp and implanted in the aortic position with the everted miniroot technique. This was followed by the pulmonary homograft implantation in the pulmonary position. The arrow shaped sternotomy was closed with a technique developed by us, using an “X” sternal wire at the level of the transversal sternotomy, which was further stabilized with a “butterfly” configuration between the “X” wire and the next proximal standard wire. Results: The cardiopulmonary bypass and aortic cross clamp time were between 144-148 and 84-87 minutes respectively. The intervention was uneventful, with very good intraoperative transoesophagial echocardiography results. The postoperative course was straightforward (1 day in ITU, 7 days in-hospital stay). The 3-month follow-up results were excellent regarding both the echocardiographic and cosmetic results. Conclusions: The arrow shaped ministernotomy offers the advantage of a wider, more comfortable approach for both the aortic and pulmonary conduits, making it safer for minimally invasive Ross procedures, compared to the partial “J” sternotomy approach.