Konno Procedure

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Eur J Cardiothorac Surg. 2004 May;25(5):742-7.
Comment in: Eur J Cardiothorac Surg. 2004 Sep;26(3):660; author reply 661.
Ross and Ross-Konno procedure in children and adolescents: mid-term results.
Hraska V, Krajci M, Haun Ch, Ntalakoura K, Razek V, Lacour-Gayet F, Weil J, Reichenspurner H.
Department of Pediatric Cardiac Surgery, University Hospital Hamburg-Eppendorf, Martinistrase 52, 20246 Hamburg, Germany. v.hraska@uke.uni-hamburg.de

OBJECTIVES: The aim of the study was to analyze mid-term results of aortic root replacement with pulmonary autograft in children and adolescents in two centers. METHODS: From December 1997 through August 2003, a total of 66 patients underwent the Ross procedure in two centers. Indication for Ross procedure was predominantly aortic stenosis in 24 patients and predominantly aortic regurgitation (AR) in 22 patients. Twenty patients with severe left ventricular outflow tract obstruction (LVOTO) underwent Ross-Konno procedure. No patient had a geometric mismatch of more than 5 mm in favor of the aortic annulus. RESULTS: There was no early death. One patient died 3 months after surgery due to bacterial endocarditis. Survival on median follow-up period of 2.4 years was 98.5%. Neo-aortic regurgitation was none in 29 (44%) patients, trivial in 35 (53%) patients and mild in 2 (3%) patients. One patient (1.5%) needed aortic valve replacement because of autograft failure. Actuarial freedom from more than trivial neo-aortic regurgitation, or aortic valve replacement was 95% at 5 years follow-up. There was no patient either with recurrent LVOTO or significant aortic root dilatation. Freedom from redo was 93% at 5 years of follow-up. There had been a significant reduction (P = 0.001) and normalization in the left ventricle diastolic diameter index and left ventricle mass index, respectively, within 3-12 months after operation. Sixty-three percent of all operated patients are without medication; no one is on anticoagulation therapy. CONCLUSIONS: Our 7 years experience with the Ross and Ross-Konno operation has shown excellent mid-term results, with mortality rate approaching zero in both simple and complex left heart lesions, even in the neonates and infants. It is a procedure of choice in children with severe anomaly of the aortic valve and/or left ventricular outflow tract obstruction. The main concern is dilatation of the neo-aortic root leading to progression of AR, especially in the settings of geometric mismatch of aortic and pulmonary roots and bicuspid, regurgitant aortic valve. The risk of autograft failure in these specific subsets of patients remains to be determined.

Ann Thorac Surg. 2003 Jan;75(1):147-51; discussion 151-2.
The modified Konno procedure for complex left ventricular outflow tract obstruction.
Caldarone CA, Van Natta TL, Frazer JR, Behrendt DM.
Division of Cardiothoracic Surgery, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA. chris-caldarone@uiowa.edu

BACKGROUND: Complex left ventricular outflow tract (LVOT) obstruction with normal aortic valve function requires aggressive resection in the subaortic region and preservation of the aortic valve. The modified Konno procedure allows generous exposure of the LVOT from the left ventricular apex to the inter leaflet trigones of the aortic valve. Widespread use of this procedure has been limited by concern over injury to the aortic valve, the conduction system, and possibility of residual ventricular septal defect (VSD). METHODS: Retrospective analysis of pertinent data for all patients undergoing the modified Konno procedure (1994 to 2001) at the University of Iowa were reviewed. RESULTS: The modified Konno procedure was used in 18 patients (age 1 to 31) for LVOT obstruction associated with diffuse narrowing of the LVOT (n = 7), a discrete fibrous ring (n = 7), or a fibrous ring associated with abnormal mitral attachments (n = 4). Eight patients had previously undergone LVOT resection. There were no perioperative deaths. Estimated LVOT peak gradients by echocardiogram were 70.4 +/- 24.2 mm Hg (preoperative) and 19.2 +/- 20.4 mm Hg (postoperative) at most recent followup (p < 0.001 vs preop). Aortic insufficiency was moderate in one patient (present preop) and mild or less in all other patients. There were no cases of permanent heart block. Small residual VSDs were present in five patients (28%). Median follow-up is 3.1 years. CONCLUSIONS: The modified Konno procedure can effectively relieve complex LVOT obstruction and preserve aortic valve function. Extension of this procedure for use in the initial presentation of LVOT may be appropriate in cases at increased risk of recurrent LVOT obstruction.

Ann Thorac Surg. 2001 Sep;72(3):823-30.
The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function.
Ohye RG, Gomez CA, Ohye BJ, Goldberg CS, Bove EL.
Division of Pediatric Cardiovascular Surgery, University of Michigan School of Medicine, Ann Arbor 48109, USA. ohye@umich.edu

BACKGROUND: The Ross procedure has been increasingly applied to neonates and infants. Addition of a modified Konno-type enlargement of the aortic annulus allows the application of this procedure to neonates and infants with significant annular hypoplasia. The potential for growth and the proven durability make the autograft an ideal aortic valve replacement. METHODS: Between March 1993 and December 2000, 10 patients under 1 year of age underwent a Ross/Konno procedure at our institution (range, 2 to 349 days; median 16). All patients had severe to critical aortic stenosis. All patients required aortic annulus enlargement for size mismatch between the aortic and pulmonary valves. RESULTS: There were no deaths at a median follow-up of 48 months (range, 1 to 74 months). All patients had none to mild aortic stenosis on Doppler echocardiography. Eight patients had a 0 to 1+ aortic insufficiency, 1 patient had a 2+ aortic insufficiency, and 1 patient had a 3+ aortic insufficiency. Aortic annular dilatation was not observed. Aortic sinus dilatation occurred initially (mean change in z-value: 0 to 12 months, +2.1) and then stabilized (mean change in z-value: 12 to > 36 months, +0.6). No patient required additional procedures for aortic valve disease. Two patients required three pulmonary allograft replacements. CONCLUSIONS: The Ross procedure with a modified Konno-type enlargement of the aortic annulus is an excellent approach to aortic valve disease in the neonate and infant. The procedure can be accomplished with low morbidity and mortality, and low rates of reoperation. The pulmonary autograft demonstrates durability without developing aortic stenosis, aortic insufficiency, or progressive dilatation. Enlargement of the aortic annulus parallels somatic growth.

Kyobu Geka. 2000 Oct;53(11):939-43.
Modified Konno procedure for a child with left ventricular outflow tract obstruction after repair of atrioventricular septal defect: a transaortic transpulmonary approach
Sakurai H, Maeda M, Miyahara K, Nakayama M, Murayama H, Hasegawa H.
Department of Cardiovascular Surgery, Shakaihoken Chukyo Hospital, Nagoya, Japan.

A one-year-old infant underwent repair of atrioventricular septal defect with common orifice. About 2 years later, echocardiography revealed a left ventricular outflow tract obstruction for the first time. Because of progression of the obstructive lesion, a modified Konno procedure through a transaortic transpulmonary approach was later performed at 8 years old, and the postoperative course was uneventful. This is a useful procedure for left ventricular outflow tract obstruction with normal aortic valve and aortic annulus, because it can both preserve a native aortic valve and dose not necessitate right ventriculotomy in resection of hypertrophied muscle and patch enlargement of interventricular septum.

J Thorac Cardiovasc Surg. 1996 Jan;111(1):158-65; discussion 165-7.
Aortoventriculoplasty with the pulmonary autograft: the "Ross-Konno" procedure.
Reddy VM, Rajasinghe HA, Teitel DF, Haas GS, Hanley FL.
Division of Cardiothoracic Surgery, University of California San Francisco, USA.

BACKGROUND: For patients with complex left ventricular outflow tract obstruction, including hypoplastic aortic anulus with or without severe diffuse subaortic stenosis, various aortoventriculoplasty procedures (e.g., Konno procedure and its modifications; extended aortic allograft root replacement) are important management options. In younger patients, however, reoperation for valve replacement is inevitably required, and anticoagulation issues pose additional problems. The pulmonary autograft provides a promising option for aortic valve replacement as part of the aortoventriculoplasty procedure in children. Long-term follow up shows that the pulmonary autograft functions well as the systemic arterial (neoaortic) valve and that valve growth occurs. METHODS: Between July 1993 and May 1995, 11 patients 4 days to 17 years old (median 12 months) underwent aortoventriculoplasty with pulmonary autograft (Ross-Konno procedure). The diagnoses were aortic stenosis with or without subaortic stenosis (n = 8), Shone complex (n = 2), and interrupted aortic arch with subaortic stenosis (n = 1). On average, 1.9 previous interventions had been performed per patient, including a previous Konno procedure in one patient. The aortic root was replaced with a pulmonary autograft valve. The left ventricular outflow tract was enlarged with a Dacron polyester fabric patch in two patients, with an allograft aortic patch in two patients and a right ventricular infundibular free wall muscular extension harvested in continuity with the autograft in seven patients. RESULTS: Intraoperative transesophageal echocardiographic assessment revealed mild aortic insufficiency in one patient. One patient had a residual left ventricular outflow tract gradient of 15 mm Hg. Significant complications were cardiac tamponade from bleeding (n = 1) and complete heart block necessitating a permanent pacemaker (n = 1). Follow-up ranged from 2 weeks to 16 months. To date, there have been no late deaths or reoperations. Follow-up echocardiography revealed mild autograft insufficiency in one patient and a 16 mm Hg residual left ventricular outflow tract gradient in one patient. CONCLUSIONS: Initial experience suggests that aortoventriculoplasty with the pulmonary autograft is an excellent alternative for young patients with complex left ventricular outflow tract obstruction. Because the pulmonary autograft has

Kyobu Geka. 1991 Oct;44(11):957-60.
A surgical experience of aortoventriculoplasty (Konno's procedure) for aortic stenosis associated with hypoplasia of aortic valve ring progressed after the repair of supravalvular aortic stenosis
Hiramatsu Y, Sakai A, Maki S, Abe Y, Nomura T, Osawa M.
Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital.

A 14-year-old boy with aortic stenosis associated with hypoplasia of aortic valve ring underwent aortoventriculoplasty (Konno's procedure) successfully nine years after the repair of supravalvular aortic stenosis. His aortic annulus diameter before enlargement was 17 to 18 mm and after the procedure, a 25 mm St. Jude Medical prosthetic valve was implanted. It was adequate size for this large-sized student (173 cm in height, 67 kg in weight). After this operation, mild stenosis of right ventricular outflow tract was presented probably due to insufficient reconstruction of right ventricular outflow for such a dramatic enlargement of aortic annulus. Although this procedure makes possible to implant more than three-size larger prosthetic valve without major complications, we have to be careful about preventing right ventricular outflow tract stenosis in case of requiring enlargement over 40 or 50% of aortic annular circle.

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