A stitch in time saves nine?

The recent resurgence of the Ross procedure has increased the visibility of this third alternative option to address aortic valve (AV) disease in younger patients (1). In addition to avoiding the pitfalls of bioprosthetic or mechanical AV replacement, the Ross procedure has been shown to restore life expectancy to that of the general population (2). Nevertheless, the procedure is technically demanding, with established volume-outcome relationships, and may not be feasible in those patients having certain anatomic features (3). Without careful attention to surgical technique and patient selection, the risk of late autograft failure resulting in aortic insufficiency (AI) may necessitate redo sternotomy and autograft reintervention, thereby negating the survival benefits of autograft implantation. Nevertheless, the contemporary rates of reintervention are low at experienced centers (4). Since early valve insufficiency is thought to be a risk factor for progressive hemodynamic deterioration, there has been significant focus on predicting, preventing, and correcting autograft valve insufficiency at the initial operation.

Chauvette and colleagues present their single-surgeon experience of managing of intra-operatively detected significant autograft insufficiency necessitating additional autograft valve intervention following the initial cross-clamp period (5). Among 675 patients undergoing the Ross procedure over 14 years across two different institutions, 3% of patients required unexpected repair of the autograft valve utilizing additional aortic cross-clamping at the time of initial surgery. Overall outcomes were favorable with low rates of greater than mild AI after a median follow-up of 3 years. Only one patient required conversion to Bentall at the index hospitalization. Commissuroplasty and/or central plication were utilized to address valve pathology with median total cardiopulmonary bypass time approaching four hours. Post-operative complications were minimal and the median length of stay was 6 days. The authors suggest that intervention for autograft AI results in excellent valve competency with durable mid-term results.

Though contraindications for the Ross procedure have been debated, aberrant pulmonary valve anatomy potentially predisposing to autograft insufficiency is considered a reason for pause as a relative contraindication in the consideration of a patient’s eligibility for undergoing a Ross procedure. Though not previously reported with the exact numbers and not described in this study, a proportion of patients considered for Ross may potentially be declined due to preoperative echocardiographic imaging or intraoperative visual inspection of abnormal pulmonary valve anatomy. In one autopsy study, 22% of hearts demonstrated fenestrations of at least one pulmonary valve leaflet and less than 1% of pulmonary valves were bicuspid (6).

Tremendous value would be added to this study if additional details were provided regarding the specific preoperative imaging criteria that warrant pivoting from a planned Ross procedure to prosthetic valve replacement as well as the percentage of patients that are determined intra-operatively by visual inspection to no longer be candidates for the Ross procedure due to issues regarding autograft valve anatomy and function. Large pulmonary valve fenestrations are considered an absolute contraindication to a Ross procedure, though there are reports in which repair is considered (7). The presence of a bicuspid pulmonary valve is also felt to be a relative contraindication, and only one of the 22 patients undergoing autograft repair in this report had a bicuspid valve (7).

In this series, only 14% of patients demonstrated mild pulmonary insufficiency on preoperative transesophageal echocardiography with the remainder showing trace or no pulmonary insufficiency. The option to repair any potentially correctable lesions may further expand the pool of patients of possible Ross procedure candidates in lieu of prosthetic valve replacement, though based on anatomic studies in the general population, this may not add a significant number of patients (6).

To fully grasp the entire scope of potential Ross candidates and to identify opportunities for surgical correction of potential anatomic abnormalities as a means to expand the overall candidate pool, it is imperative to explore and report the important factors for or against the Ross procedure, including anatomic and patient-specific factors as well as surgeon expertise. Application of the aforementioned valve repair principles to address intrinsic abnormalities in the autograft valve represents a small segment of those patients requiring autograft intervention for AI at the time of the Ross. Thus, surgical technique for valve implantation may be the primary contributor to autograft AI and efforts should focus on optimizing both operative skill and implantation strategy.

In addition to anatomic contributors related to the pulmonary valve, it is important to consider technical factors in autograft implantation as a potential source of autograft insufficiency. Any asymmetry of the conduit due to twisting of the autograft or uneven implantation, either proximally at the annulus or distally at the anastomosis between the autograft and either a Dacron interposition graft or the native aorta, may induce insufficiency. Additionally, the autograft must be carefully handled to ensure there is no inadvertent injury to the leaflets and that the leaflets are not tethered within the annular suture line. These critical steps of the operation may be commonplace to experienced Ross surgeons but can become stumbling blocks in those who are less familiar with the Ross procedure or complex root surgery.

Techniques for valve preservation and AV repair are well-established and have been applied in patients with native bicuspid AV as well as native tricuspid AV anatomy. Despite anatomic (thinner cusps, greater geometric height) (8) and biomechanical (stress, elasticity) (9) differences in the pulmonary valve, the authors demonstrate that principles of AV repair can be successfully applied to address autograft valve AI. In this study, techniques for valve repair consisted of commissuroplasty for commissural AI, central plication for eccentric AI, or a combination thereof in mixed pictures of AI. The literature on pulmonary valve repair is sparse and thus repair principles have been extrapolated from lessons learned from native AV repair for both native bicuspid and tricuspid aortic anatomy. Importantly, full understanding of the anatomy and physiology of the autograft within the aortic root as well as strategies to mitigate common mechanisms of autograft failure, such as annular dilatation, must be accounted for. In this study, the Ross procedure was performed using a full root replacement technique and annular stabilization was accomplished with a Dacron graft which theoretically reduces the risk of late AI from annular dilatation.

The importance of transesophageal echocardiogram imaging to support these procedures cannot be understated. A comprehensive exam by an experienced sonographer both at the start of the operation prior to skin incision as well as at completion of the procedure after coming off bypass provide invaluable data to guide both surgical decision-making and evaluate the need for additional valve intervention in the setting of post-procedure AI as a means to ensure optimal long-term valve durability (10). Importantly, the nature of any AI jet post-procedure should be carefully examined as this can provide anatomic details as to the mechanism of AI and thereby dictate the approach for autograft valve repair. Intra-operative echocardiographic findings including coaptation height and motion of the cusps, as well as the presence of any AI, have been correlated to durability of native AV repair (11). Both 2D and 3D images as well as color Doppler flow are extremely informative for assessing regurgitation. While the breadth of AI repair strategies is wide and potentially complex, the authors were able to achieve satisfactory results with the application of just two repair techniques. This provides optimism for less experienced surgeons towards achieving a durable repair but also serves as a warning that identification of a need for more complex repairs (e.g., leaflet augmentation) should warrant a pause and reconsideration for possible conversion to prosthetic valve replacement.

Ensuring no greater than mild AI at the conclusion of the Ross procedure is critical for long-term success of these operations. Evidence suggests that the need for cusp repair has been demonstrated as an independent predictor of AI recurrence (12). Particularly with an unsupported aortic root, progressive AI will lead to left ventricular dilatation and well as annular dilatation thereby worsening the degree of AI. It also deserves mention that the majority of patients (45%) in this study had aortic stenosis as their presenting pathology, while 27% had mixed valve disease and 27% had isolated insufficiency. Thus, introduction of new AI would likely be poorly tolerated in the unconditioned left ventricle in over half of these patients. This underscores the need to identify and correct any significant degree of valvular insufficiency, either during the operation or prior to discharge, in order to prevent deleterious effect of chronic volume overload on the left ventricle.

Correction of intra-operative autograft valve insufficiency adds an additional layer of complexity to an already complex operation and the impact of an additional cross clamp period and further extending the cardiopulmonary bypass period should not be minimized. Every attempt should be made to anticipate and plan for the possibility of autograft valve insufficiency. In centers with less familiarity with the Ross procedure, the threshold to convert to a Bentall operation should be lowered in cases of questionable valve competence. The excellent results from authors should be extrapolated very carefully as outcomes from one of the most high-volume Ross surgeons in the world may not be generalizable to all surgeons. Ultimately, a safely executed prosthetic AV replacement may be a superior choice to a marginal Ross procedure with uncertain long-term durability.

In conclusion, Chauvette et al. have demonstrated that a simple stitch for central plication to correct central AI or commisuroplasty to address commissural AI can result in durable outcomes and can prevent the need for prosthetic valve replacement and thus preserve the survival benefits afforded by pulmonary autograft implantation (5). Longer-term results are necessary to verify whether these promising short-term outcomes translate to sustained durability over decades of follow-up and whether the beneficial effects of the Ross procedure, namely the restoration of normal life expectancy, can be preserved in this subpopulation. Pre-operative imaging should be carefully reviewed to anticipate potential risks of post-operative AI yet, in experienced hands, the option for salvage of the autograft with valve repair appears feasible. Nevertheless, given that autograft failure does not generally occur until after 2–3 decades, any firm conclusions on the durability of the current repair techniques described would be premature until a similar length of follow-up has been achieved.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Shanghai Chest. The article has undergone external peer review.

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0020/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0020/coif). The authors have no conflicts of interest to declare.

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