Anatomical mismatch of the pulmonary autograft in the aortic root may be the cause of early aortic insufficiency after the Ross procedure.

OBJECTIVE: Early aortic insufficiency can be a problem after the Ross procedure. Anatomical mismatch and an inexact surgical technique may lead to distortion of the normal pulmonary valve geometry and subsequent incorrect leaflet coaptation and valve insufficiency. In this study, we assessed the efficacy of changing and improving the surgical technique to minimize the early pulmonary autograft valve failure. The modifications and the strategy are discussed.

METHODS: From January 1995 to February 1999, a total of 77 adults underwent the Ross procedure for aortic valve replacement at Sahlgrenska University Hospital. The operative technique used was full free-standing aortic root replacement with a pulmonary autograft in all cases. In the first 24 cases, the diameter of the pulmonary roots was seldom measured, eye-balling was used to exclude anatomical mismatch due to a dilated aortic root, and only one attempt of correction was made, which failed. In the other 53 cases, the technique was improved by: (1) reducing the aortic anulus diameter in cases with moderate dilatation; (2) excluding cases with severe dilatation of the aortic annulus; (3) adjusting the diameter of the sinotubular junction of the aorta to the diameter of the sinotubular junction of the pulmonary artery; (4). reimplanting the left ostium in the autograft, and (5) changing the proximal anastomosis technique.

RESULTS: In this study, we had an early aortic incompetence of grade 2 in eight patients among the first 24 patients. In the other 53 patients, postoperative echocardiography at 1 week revealed aortic insufficiency of grade 2 in two patients.

CONCLUSIONS: Aortic insufficiency after the Ross procedure can be minimized by patient selection, intraoperative correction of anatomical mismatch and improved surgical technique.