The Ross Procedure: New Insights Into the Surgical Anatomy

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The Ross Procedure: New Insights Into the Surgical Anatomy Horia Muresian, MD, PhD The Annals of Thoracic Surgery Volume 81, Issue 2, Pages 495-501 (February 2006) DOI: 10.1016/j.athoracsur.2005.07.051 Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 The aortic root, posterior view, of the adult heart. The tricuspid valve was retracted from the septum revealing the membranous septum (ms), which is continuous with the interleaflet triangle between the noncoronary sinus (NC) and the right coronary sinus (R). The mitral-aortic curtain is continuous with the triangle between the left coronary sinus (L) and the NC sinus. The levels of the basal ring (BR) and sinotubular junction (STJ) are marked with dotted lines. (Ao = aorta; RCA = right coronary artery.) The Annals of Thoracic Surgery 2006 81, 495-501DOI: (10.1016/j.athoracsur.2005.07.051) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Adult heart dissected through the ventricular outflow tracts. Note the almost perpendicular disposition of the aortic and pulmonary roots, the general shape of the right ventricular outflow tract (RVOT) winding around the left ventricular outflow tract and the nonplanar disposition of the interventricular septum. The outlet septum corresponds to the dotted line. The RVOT is completely muscular whereas the posterior third of LVOT is formed by the anterior mitral leaflet (AML). The space between aorta (Ao) and pulmonary trunk (PT) lodges the left coronary artery (LCA++ [here already bifurcated in the circumflex and left anterior descending arteries]). Note the close relationship between the Ao, PT, left atrial appendage (LAA), and LCA. The cleavage plane between the two roots is evident distally, while proximally, it becomes less distinct. Note also the thinner and shorter posterior wall of the autograft. (A = anterior tricuspid leaflet; CS = crista supraventricularis; L = left coronary sinus; NC = noncoronary sinus; P = posterior tricuspid leaflet; R = right coronary sinus; S = septal tricuspid leaflet; TM = tricuspid medial papillary muscle.) The Annals of Thoracic Surgery 2006 81, 495-501DOI: (10.1016/j.athoracsur.2005.07.051) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Left-basal view of the adult heart. The pulmonary trunk (PT) is retracted in order to expose the infundibular arteries (*) and the cleavage plane between the arterial trunks. In this specimen, a tendon of infundibulum is readily visible (x). The left atrial appendage (LAA) is also retracted to demonstrate the origin of the left coronary artery (LCA), of the circumflex branch (Cx), and of the left atrial branch (LAB). Note also the double origin of the sinus node artery and the retroaortic anastomotic circle between the LAB and right atrial branches (RAB). The right infundibular arteries are more conspicuous and have origin in an accessory right coronary. The posterior left infundibular artery originates proximal to S1; the lateral left artery, between the S1 and S2. Note also the large caliber of the S2 in this case. A branch (<<) from the RAB is given to the aortic root. (Ao = aorta; D1, D2 = diagonal branches; LAD = left anterior descending artery; RAA = right atrial appendage; RCA = right coronary artery; S1, S2, S3 = anterior septal arteries.) The Annals of Thoracic Surgery 2006 81, 495-501DOI: (10.1016/j.athoracsur.2005.07.051) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Infundibular vessels after autograft excision of the adult heart. The anterior septal artery S1 has a very proximal origin (and remote from the infundibulum); S2 is the largest. A cleavage plane exists between the muscular layers of the septum. There are three right infundibular arteries originating in an accessory right coronary and only one on the left (cut). Note also the position of the anterior septal arteries S1, S2, and S3 with respect to the infundibulum. The main septal artery, when not the first, shows a longer retroinfundibular course. (Ao = aorta; Cx = circumflex branch; LAD = left anterior descending artery; LCA = left coronary artery; RCA = right coronary artery.) The Annals of Thoracic Surgery 2006 81, 495-501DOI: (10.1016/j.athoracsur.2005.07.051) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Interventricular septum and aortic root of an adult heart. The infundibulum was removed. The right ventricle cavity is widely open. The aortic sinuses were excised, revealing the interleaflet triangles. The coronary buttons are still attached to the aorta by a rim of tissue. The aortic root, corresponding to the space between the left coronary sinus (L) and right coronary sinus (R), and to the outlet septum, is vascularized by two early septal branches with origin in the proximal left anterior descending artery (LAD). In this specimen, S3 is the largest. Note its branches to the aortic root, to the tricuspid medial papillary muscle (TM), and the trabecula septomarginalis. A left infundibular artery (*) is visible, with origin between S3 and S4. (A = anterior tricuspid leaflet; Cx = circumflex branch; D1, D2 = diagonal branches; LCA = left coronary artery; P = posterior tricuspid leaflet; RCA = right coronary artery; S = septal tricuspid leaflet; S1, S2, S3, S4 = anterior septal arteries. The Annals of Thoracic Surgery 2006 81, 495-501DOI: (10.1016/j.athoracsur.2005.07.051) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Vascularization of the aortic root of the adult heart. In a more advanced dissection of the aortic root, the tricuspid medial papillary muscle (TM) was retracted. The branches to the aortic root given by S1 (<<) are large and travel toward the membranous septum (dotted line) where they anastomose with the atrioventricular node artery (AVNA) and with the posterior septal artery branches (p [from the right coronary artery in this case]). (LAD = left anterior descending artery; LCA = left coronary artery; p = posterior septal arteries; S1, S2 = anterior septal arteries.) The Annals of Thoracic Surgery 2006 81, 495-501DOI: (10.1016/j.athoracsur.2005.07.051) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions