Reoperative quadrivalvular surgery including Ross reversal for complex left ventricular outflow tract obstruction

The case is presented of a congenital left ventricular outflow tract (LVOT) obstruction caused by a malpositioned hypertrophied papillary muscle. The patient was initially treated with subaortic membrane resection that did not address the papillary muscle. Subsequently, she underwent a Ross procedure after her native aortic valve had deteriorated. Neither of these operations alleviated the symptoms, nor did they relieve the LVOT obstruction caused by the papillary muscle. Shortly after the Ross operation the autograft dilated and caused severe regurgitation, whereupon the patient's symptoms worsened. Herein are presented the authors' considerations in repairing or replacing each of the patient's four valves, including reversing the Ross procedure, in an attempt to repair the congenital defect and minimize the need for future surgery.