Ross Procedure After Arterial Switch Operation?

Arterial switch operation (ASO) has been the standard anatomic repair for D-transposition of the great arteries (d-TGA) since Jatene et al. first described it in 1975. While survival is excellent, some patients develop late complications requiring reoperation, including neo-aortic regurgitation (neo-AR) and root dilatation (ARD). Mechanisms of neo-AR are multifactorial, and management depends on whether the pathology is leaflet- or root-driven. When neo-AR is secondary to ARD, options include valve-sparing root replacement (VSRR) or composite root replacement (Bentall procedure) using either a mechanical or a bioprosthetic valve. In cases of isolated neo-AR without significant ARD, valve repair with annular stabilization can be considered. Alternatively, such cases may be managed with the Ross procedure, first described as 'Switch-Back Ross' by Hazekamp et al., although this approach remains less commonly employed. The specific surgical choice should integrate anatomy, physiology, and patient-specific factors within a shared decision-making framework. This review focuses on the Ross procedure after ASO, with emphasis on operative pearls, expected complications, and durability considerations. We illustrate these principles through the case of a 19-year-old man, late after ASO, who presented with severe neo-AR and mild ARD. He underwent a 'supported' Ross with external annuloplasty and recovered uneventfully. This case underscores the feasibility of the Ross procedure when valve repair is nondurable and emphasizes annular stabilization as key to long-term success, contributing to the limited literature on this approach in post-ASO patients.