A novel, simplified protected Ross technique: The "Seattle shawl" procedure

Autograft dilation and subsequent aortic regurgitation remain a challenge in the long term after the Ross procedure in adults. We have developed a novel technique for a modified Dacron wrap of the pulmonary autograft to help stabilize and mitigate this issue.

In 2022, we formalized a patient-specific tailored algorithm for autograft protection during the Ross procedure, including use of a modified Dacron wrap ("Seattle shawl"). This technique involves the use of a Valsalva graft, which is "keyholed" to facilitate coronary button implantation on the autograft and then wrapped around the pulmonary autograft. A total of 6 patients have undergone the Seattle shawl procedure. Mean follow-up time was 11.8 months (range, 4-17 months).

All 6 patients had bicuspid aortic valves with severe aortic regurgitation. Mean aortic annulus size was 30.3 mm, and mean aortic root diameter was 4.4 cm. There were no perioperative strokes, reinterventions, or mortalities. All patients had mild or less aortic regurgitation on the most recent echocardiogram. Aortic root diameters were between 3.2 and 3.9 cm on the most recent imaging examination. There were no mortalities or complications observed during the follow-up period.

Pulmonary autograft dilation remains a challenge postoperatively after the Ross procedure in adults. Multiple interventions have been used to minimize this phenomenon. These include technical modifications such as annuloplasty rings or complete inclusion of the autograft within a Dacron graft. We present a novel, straightforward technique for autograft protection using a modified Valsalva graft. Early outcomes in 6 patients appear promising with this technique.