The Ross procedure is one option for the treatment of aortic stenosis in pediatric patients, young adults, and women of reproductive age. Pulmonary autograft in the aortic position is the only valve replacement conducted with living tissue and with growth capacity. Accordingly, this grafting procedure offers advantages over mechanical prostheses, such as a projected life expectancy comparable to that of the unaffected population, no need for anticoagulation, and suitability as a good alternative in young populations.1

Its postprocedural complications include autograft dilatation, valve regurgitation (60.5% vs 23.7% of patients requiring reoperation),2 or a combination of the two. Regurgitation due to lack of coaptation secondary to neoaortic root dilatation is frequent, as well as regurgitation without dilation, which usually develops at an earlier stage after the Ross procedure.2

We present the cases of 3 patients managed in our center who had dilatation and severe pulmonary autograft regurgitation and who were treated with conservative surgery involving neoaortic valve resuspension (David I procedure).3

The median age of our patients at reintervention was 29 years (23, 29, and 36 years), similar to other series.2

The 3 patients underwent a pediatric Ross procedure involving placement of a pulmonary autograft in the aortic position with full root replacement and coronary artery reimplantation, the most commonly used technique.4 The mean patient age at the first surgery was 12.7 years (9, 13, and 16 years). The main indication for surgery was clinical follow-up findings of progressive dilatation of the neoaortic root, mainly, and pulmonary autograft regurgitation (secondary to the dilatation), as well as elevated gradients in the pulmonary conduit.

Reintervention was indicated a mean of 16.7 years (14, 16, and 20 years) after the first surgery, similar to other series.5

All 3 patients underwent aortic root repair using the David technique6 and the conduit from the right ventricle to the pulmonary artery was replaced after dissection of the autograft up to the previous Ross procedure suture area. In our opinion, this maneuver greatly facilitates the mobilization of the coronary ostia and is advisable regardless of their functional status. Next, we resected the dilated Valsalva sinuses, preserving the valve. For replacement of the aortic root, we used a straight 30-mm Dacron tube and performed a valve resuspension, with appropriate coaptation identified in a static saline test (figure 1A-D).

Figure 1.

A: dissection of the pulmonary autograft (1). Enucleation of the previous pulmonary conduit (2). B: suspension of the commissures. Mobilization of the coronary ostia (2). C: placement of the Dacron tube and fixation of the commissures with leaflet coaptation. D: reimplantation of the coronary ostia.

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In the pulmonary position, we implanted a porcine biological pulmonary conduit (BioPulmonic) in 2 patients and a pulmonary homograft in 1 patient.

The mean cardiopulmonary bypass time was 218minutes while the cross-clamp time was 175minutes.

The postoperative course was incident-free, and predischarge echocardiography revealed no significant residual valve regurgitation (figure 2C-D). During follow-up, 2 patients had mild neoaortic regurgitation; all patients had low transvalvular gradients and the pulmonary conduit was functioning normally. The longest follow-up was 27 months.

Figure 2.

A: dilation of the neoaortic root in computed tomography angiography. B: preoperative ultrasound showing severe neoaortic regurgitation. C: postoperative ultrasound showing mild neoaortic regurgitation (long axis). D: postoperative ultrasound showing mild neoaortic regurgitation (short axis).

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Based on our initial experience, we conclude that preservation of a dysfunctioning pulmonary autograft after the Ross procedure is feasible and safe.

Valve resuspension using the technique described by David and Feindel6 allows preservation of the native valve and avoids its replacement with a prosthesis.

By maintaining the native valve, the advantages of the Ross procedures in terms of life expectancy vs mechanical prostheses are possibly preserved.1 The results show the feasibility of a valve preservation technique that provides the benefits of native valve preservation in this young population. Conservative autograft surgery is a safe and feasible procedure. To evaluate the long-term course of the neoaortic valve after this technique, with a view to a paradigm shift, a longer follow-up and larger sample size are required.