Cardiovascular Surgery, Vol. 11, No. 3, pp. 229–230, 2003  2003 The International Society for Cardiovascular Surgery Published by Elsevier Science Ltd. All rights reserved. 0967-2109/03 $30.00 www.elsevier.com/locate/cardiosur doi:10.1016/S0967-2109(02)00169-2 BRIEF SURGICAL TECHNIQUE Pericardial collar modification for Ross procedure T. Sarioglu, E. Erek, Y. K. Yalc ¸ınbas, E. Salihog ˘ lu, A. Sarioglu and S. Tekin Istanbul Memorial Medical Center, Okmeydan, Istanbul, Turkey Although the surgical technique of the Ross operation has been improved over the years, there are still some technical difficulties: (1) The possibility of damage to first septal artery during harvesting and reconstruction of right ventricular outflow tract (RVOT). (2) Weak pos- terior anastomotic area during RVOT reconstruction. (3) Persistent bleeding from septal dis- section site of pulmonary autograft. To deal with these difficulties, we used a 1-cm wide pericardial strip (pericardial collar) which was sutured to epicardium at the posterior and septal edge of the RVOT. The conduit used for the reconstruction of pulmonary outflow was then sutured to this pericardial strip at the posterior part of the anastomosis. We found this tech- nique very useful to create a safe and strong margin for the posterior suture line. Persistent bleeding from septal dissection site can be also avoided using this modification by diverting the bleeding site into the right ventricular cavity.  2003 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved. Keywords: pulmonary autograft, Ross procedure, right ventricle outflow tract reconstruction Introduction For many years Ross operation was considered as a technically demanding high risk operation and was not accepted by most of the cardiac surgeons until impressive long-term results became available in the late 1980s [1]. One of the most severe complications of the operation is damage to the first septal artery during autograft harvesting or pulmonary outflow conduit implantation. Weakness of posterior suture line at the RVOT and persistent bleeding from the septal dissection site are other difficulties of the oper- ation. In this article we describe a new technique to avoid these problems in order to make Ross operation eas- ier and safer. Technique The procedure is conducted through a median ster- notomy, bicaval cannulation and standart cardio- Correspondence to: Dr. E. Erek, Istanbul Memorial Hospital, Piyale- pasa Bulvarı 80270 Okmeydan, Istanbul, Turkey CARDIOVASCULAR SURGERY JUNE 2003 VOL 11 NO 3 229 pulmonary bypass with membran oxygenator under moderate hypothermia. The aortic and pulmonary roots are extensively dissected out. After isothermic blood cardioplegic arrest, aortic valve is resected and aortic annulus is measured with valve sizers. The pulmonary root is transected proximal to the bifur- cation and dissected down to the septum. At the proximal site, right ventricular infundibulum is opened a few milimeters below the pulmonary annu- lus with a ridge of right ventricular muscle. Care is taken to avoid the first septal branch at the posterior and septal surface. Then right and left coronary ostial buttons are excised and total root replacement technique is used. RVOT reconstruction is perfor- med after releasing the aortic cross clamp. A new ‘pericardial collar technique’ is used for RVOT reconstruction (Figure 1). A strip of pericardium 1 cm wide is sutured to the epicardial edge of the pos- terior and septal part of the RVOT. Then heterograft or homograft conduit is sutured to this pericardial strip at the posteriorpart of the anastomosis. At the anterior and lateral part of the anastomosis, conduit is sutured to the right ventricular muscle directly.