Minimally Invasive Ross Procedure in Adults, Through an Arrow-Shaped ("V" Shaped) Ministernotomy Approach

Background/Objectives: The Ross procedure is recognized for its excellent long-term outcomes in aortic valve surgery, providing superior hemodynamic performance, freedom from anticoagulation, and a low risk of valve thrombosis. The aim of this study was to evaluate the technical feasibility and early clinical outcomes of performing the Ross procedure through a minimally invasive V-shaped (arrow-shaped) partial sternotomy in adult patients. Methods: Eleven consecutive adult patients underwent a Ross procedure through a 7 cm upper midline skin incision and a V-shaped (arrow-shaped) ministernotomy sternotomy extending to the third intercostal space. Cardiopulmonary bypass was established through central cannulation. The pulmonary autograft was implanted in the aortic position using the miniroot technique, followed by implantation of a pulmonary homograft in the pulmonary position. Operative, perioperative, and early echocardiographic outcomes were prospectively evaluated. Results: All procedures were completed successfully without conversion to full sternotomy or major intraoperative complications. The cardiopulmonary bypass and aortic cross-clamp times were consistent across the series, averaging 144 and 86 min, respectively. Intraoperative transesophageal echocardiography confirmed satisfactory function of both the autograft and homograft in all patients. Postoperative recovery was uneventful, with mechanical ventilation times ranging from 4 to 8 h and intensive care unit stays of 24-48 h. No cases of stroke, renal failure, permanent pacemaker implantation, atrial fibrillation, wound infection, sternal instability, reoperation for bleeding, readmission, or mortality occurred. Patients were discharged between postoperative days 7 and 10. At 3-month follow-up, transthoracic echocardiography demonstrated preserved left ventricular function, absence of aortic regurgitation, and low transvalvular gradients in all patients. Conclusions: This initial single-center case series demonstrates the technical feasibility of performing the Ross procedure through a V-shaped (arrow-shaped) partial sternotomy in carefully selected adult patients. The approach provides satisfactory operative exposure for all components of the procedure while maintaining the advantages of minimally invasive surgery. Larger studies with longer follow-up are required to further evaluate clinical outcomes and long-term durability.