Modified Ross procedure with four different strategies for right ventricular outflow tract reconstruction

The Ross procedure remains the procedure of choice for managing unrepairable aortic valves, especially in young adults and those with active lifestyles. However, the Achilles heel of this procedure has been aortic root dilation and the potential need for reoperation that may be associated with increased risks in addition to the need for intervention on the pulmonary outflow tract. Over the years, this procedure underwent several modifications to improve long-term durability and decrease the rate of reinterventions. Modifying the Ross procedure by including an autograft inside a Dacron graft seems to have the potential advantage of stabilizing the autograft diameter, which may be associated with improved durability and decrease the need for a future reoperation. Another limitation to the widespread application of this procedure is related to the use of homografts in the reconstruction of the right ventricular outflow tract. The cost and the availability of the homografts continue to be limiting factors and, with the recent surge in the number of Ross procedures, other options for reconstruction of the right ventricular outflow tract must be considered. We present three additional options for homografts that we have successfully utilized as part of the Ross procedure during reconstruction of the right ventricular outflow tract.