Please explain the educational or technical point that this video addresses.: The landscape of aortic valve therapy has evolved substantially over the past few decades. Compared with conventional valve substitute options, the Ross procedure has certain merits for young and middle‐aged adults. The fundamental driving force for the clinical advantage of the Ross operation is not only the long‐term advantages of survival, avoidance of anticoagulant therapy, rare endocarditis, and infrequent reintervention, but also the fact that the autograft is alive: the leaflets retain the native valve physiology and contractile and neurohumoral responsiveness, with resultant superior hemodynamics and quality of life. The excellent clinical outcomes are supported by the modern specific technical elements: trimming of any excess muscle off the autograft; trimming of any excess autograft above the neosinotubular junction; placement of the autograft deep into the left ventricular outflow tract by meticulous attention to each suture (sub-annular implantation for external annulus support); and providing external supports of the autograft annulus and the neosinotubular junction using various materials, particularly in patients with aortic insufficiency or large aortic annulus. However, achieving these technical elements can be highly demanding. We describe a new technique, Inversion-Reversion Technique, that suffices these modern Ross technical elements in a simplified fashion. This technique allows excellent visibility of the autograft and native aortic annulus despite running stitch, ease of maintaining autograft symmetry and sub-annular implantation, lessor time intensity, and reproducibility.
Please provide a 250 word summary of the surgical video being submitted.: We report a Ross procedure utilizing the Inversion-Reversion Technique. A 30-year-old male with severe aortic insufficiency in the setting of bicuspid aortic valve (Sievers type 1 with right-left raphe) without aortic aneurysm. The aortic and autograft annulus size was measured at 28 mm and 27 mm, respectively. Upon implantation, the autograft was flipped inside out (“inversion”) and was situated deep under the aortic annulus (sub-annular plane). The native commissures and raphe were confirmed to be symmetrically 120° apart. The autograft inversion allowed visibility of the autograft commissure alignment in relation to the native annulus. Using running 4-0 Prolene, suturing was started from the left-right raphe. These running 4-0 prolene sutures were loosely maintained, allowing excellent exposure without excessive suture loop tangling. The key technical element for the autograft side was that needle inserted right at the hinge point of the annulus and exited at the level or even higher than the level of the cusp insertion. The same concept applied along the membranous septum or aorto-mitral cutain. As these loosely maintained sutures were tightened using a nerve hook, autograft was pushed further down deeper towards the left ventricular outflow tract to assure autograft sub-annular plane implantation. The inverted autograft was reverted afterwards. The rest of the procedure was consistent with the standard technique. Intraoperative transesophageal echocardiography showed no aortic insufficiency with minimal transvalvular gradients. The postoperative course was uneventful. As of today, we have performed 5 Ross procedures using this technique with excellent results.
Learning Objectives:
Upon completion, participants will be able to understand important surgical elements of the modern Ross procedure.
Upon completion, participants will be able to understand why the Intervion-Reversion Technique works well to achieve modern Ross surgical elements.
