# Perioperative Considerations, Anesthetic Management and Transesophageal Echocardiographic Evaluation of Patients Undergoing the Ross Procedure

## TL;DR

The Ross procedure replaces a diseased aortic valve with a living pulmonary autograft, offering growth and avoiding lifelong anticoagulation, with renewed interest due to improved surgical techniques and outcomes.

## Contribution

The paper provides updated insights into the surgical and anesthetic management of the Ross procedure, emphasizing recent advances and improved long-term outcomes.

## Key findings

- The Ross procedure offers superior hemodynamic performance and avoids the need for lifelong anticoagulation.
- Recent surgical advances have improved the durability and success of the Ross procedure.
- Intraoperative transesophageal echocardiography is essential for monitoring valve function and ventricular performance.

## Abstract

The Ross procedure introduced a new technique for aortic valve replacement by utilizing a pulmonary autograft to replace the diseased aortic valve. This approach provides a living, dynamic valve substitute capable of growth and adaptation to systemic pressures while addressing the limitations of mechanical valves, which require lifelong anticoagulation, and bioprosthetic valves, which lack durability and growth potential. The Ross procedure offers superior hemodynamic performance and freedom from anticoagulation. While initially popular, utilization declined due to its technical complexity and concerns regarding the potential for the failure of two valves, requiring additional operations. Advances in surgical techniques, such as reinforced autografts, improved myocardial protection, and better homograft preservation, coupled with evidence of favorable long-term outcomes, have renewed interest in the procedure. Preoperative imaging with echocardiography, cardiac magnetic resonance imaging, and computed tomography angiography ensures optimal patient selection and preparation. Intraoperatively, precise autograft harvesting, accurate implantation, and meticulous right ventricular outflow tract reconstruction are critical for success. Blood conservation techniques, such as acute normovolemic hemodilution and retrograde autologous priming, are employed to minimize transfusion-related complications. The anesthesiologist plays a critical role, including meticulous monitoring of myocardial function and hemodynamics, with intraoperative transesophageal echocardiography being essential for assessing valve integrity and ventricular function. Recent studies suggest that the Ross procedure can restore life expectancy in appropriately selected patients, reinforcing its value as a surgical option for managing aortic valve disease.