Arrow Shaped Ministernotomy Approach for the Ross Procedure

Abstract

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.