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this video will demonstrate dr james tuttle's technique for the externally supported ross procedure with the sinus of el salvagraft and cono-aoroventriculoplasty immediate sternotomy is performed and the anatomy is inspected here you can compare them to the preoperative cardiac mri images all the major vessels are then circumferentially mobilized with controlling the aorta main pulmonary artery and vena cava the ventsite is then dissected out the patient is then aorto by cavalry cannulated and cardiopulmonary bypass is initiated event is placed through the right upper pulmonary vein and co2 is brought onto the field the enlarged aortic root is then dissected down to the proximal coronary arteries the aortic cross clamp is then applied and there's a transversal ortotomy above the sinotubular junction in this patient cardioplegia was delivered directly to the coronaries due to the level of aortic insufficiency which by cardiac mri was measured as moderate once cardioplegic arrest has been reached the aortic valve pathology is inspected this patient had a functionally bicuspid aortic valve with fusion of the left and right leaflets shown here on the preoperative trans-esophageal echocardiogram resulting in severe stenosis and again moderate insufficiency the pulmonary autograft is then harvested first the distal pulmonary artery is transected proximal to the bifurcation and the pulmonary valve is thoroughly inspected this patience was found to be tri-leaflet with thin mobile leaflets once the autograft is found to be suitable traction sutures are placed in the aortic valve commissures the coronary artery buttons are identified and excised once the left coronary artery button has been excised the proximal coronary artery is then mobilized off the heart to the circumflex and left anterior descending coronary artery bifurcation once the left coronary artery button has been sized and proximal coronary artery has been mobilized the right coronary artery button is then excised and the proximal coronary artery button is mobilized retraction sutures are placed in the top of both coronary artery buttons and the aortic valve is excised with 11 blade mets and bomb scissors and electrocautery the site is marked on the right ventricular outflow track through the main pulmonary artery with a right angle clamp the pulmonary autograft is then harvested anterior surface of the proximal autograft is incised two to three centimeters below the nadir of the pulmonary valve the insulin is extended ensuring adequate circumferential flap of infundibular muscle a nucleation of the pulmonary autograft is then completed by separating the autograph posteriorly from the left ventricle care is taken to avoid the first sepal perforator branch of the left anterior descending coronary artery this branch of the coronary artery typically originates behind the medial posterior commissure of the pulmonary valve and courses into the infundibular septum towards the anterior papillary muscle of the tricuspid valve both the aortic root and pulmonary autograft are sized a sinus of el salvage graft is then selected approximately four millimeters larger than the autograft in this case it was about 30 millimeters approximately 75 percent of the graft collar is then trimmed prior to autograft implantation the proximal autograph is then secured to the sinus of el salva graft the autographed commissures are aligned with the commissure alliance on the sinus of el salva graft and secured with a 5-0 prolene suture each end of those proline sutures are then run continuously towards the midpoint between adjacent commissures and tied the whole body of the sinus veil salvograft is then telescoped over the skirt the distal autograft is secured to the sinus of el salvage graft in an identical fashion the autographed commissioners are aligned with the commissioner markers on the graft and floral proline is run towards the adjacent commissure and tide the graft is then untelescoped and examined and the valve is tested by floating it with saline and pressurized autographed here is well seated within the sinus valve salvo graft and the autographed leaflets coaped well within the graft the now supported autograft is placed into the left ventricular outflow tract for securement the nadir of the autographed sinus is aligned to match the left coronary sinus of el salvo proximal anastomosis is initiated just below the nadir of the urinary sinus bocono aortal ventriculoplasty is then is then performed due to the mildly hypoplastic aortic annulus an approximately one centimeter incision is made of the right left commissure into the intraventricular septum the anastomosis is then completed anteriorly incorporating the area of left ventricular outflow track enlargement that did not require a patch the anterior suture line of the proximal autograft is then reinforced with the row of 4o pledges supported interrupted mattress sutures a defect is then created in the left sinus of el salva in the autographed with an 11 blade and high temperature ophthalmic cautery is then used to create a defect in the corresponding area in the sinus of el salva graft the left coronary artery button is then re-implanted in the autograft incorporating all three layers into the anastomosis and is carried out with a continuous fiboproline suture a 30 millimeter pulmonary homograft is then prepared the graft is trimmed at the branch pulmonary arteries the distal anastomosis is then completed with a continuous 5-0 proline suture the dilated section of the ascending aorta is then resected the commissural posts are resected and the distal supported autograft is trimmed the distal supported autograft is an anastomose to the ascending aorta with a continuous 40 proline suture and a teflon felt strip buttress an antigrade cardioplegia line is placed in the neoaortic root the supported autograft is then pressurized this allows right ventricular alkalotract bleeders to be identified and hemostasis to be achieved with electrocautery and pleasure supported sutures pressurization of the root also allows for a more accurate site to be identified for the right coronary artery button it usually fits best in the non-coronary artery sinus a defect is then created in the sported autograph and the right coronary artery button is re-implanted in identical fashion to the left coronary artery button following implantation any residual ambition attachments to the coronary artery are removed and the proximal supported autograph suture line is secured further with prevalence adhesive finally the right ventricular outflow tract is then reconstructed by the proximal pulmonary homograft being anastomosed to the right ventricular outflow tract with a continuous 5-0 proline suture the heart is de-aired the aortic cross clamp is removed and the patient was successfully weaned and separated from cardiopulmonary bypass using an ophthalmic cautery a small defect is created in the right sinus of el salva in the autograft this defect prevents blood reaccumulation between the autograft and the sinusoidal salvograft thank you very much for watching if you have any questions or comments please feel free to email me at the email address provided thank you