Surgical Relief of Left Ventricular Outflow Tract Obstruction in Adults With Congenital Aortic Stenosis and Associated Aortic Annulus Hypoplasia and/or Subaortic Obstruction

Heart Lung Circ. 2018 May;27(5):635-643. doi: 10.1016/j.hlc.2017.05.129. Epub 2017 Jun 3.

Abstract

Background: In children and adolescents, a Ross/Konno operation is commonly done to both enlarge the aortic root and provide a competent aortic valve with relief of left ventricular outflow tract obstruction (LVOTO). Optimum management is not so straightforward in adults.

Methods: Between 1995 and 2014, 16 patients of mean age 39.4 years (18-57 years) with hypoplastic aortic annulus (AA) measuring 20mm and less, and mean aortic valve/LVOT gradient of 61mmHg (30-70mmHg) presented for surgery.

Results: Eight patients with mean LVOT/AA diameter 19.6mm (18-20mm) underwent an "inclusion-cylinder" type Ross procedure (RP). Eight patients with more severe LVOT/AA obstruction, with mean diameter of 17.4mm (16-19mm) underwent mechanical aortic valve replacement (AVR) with standard Konno-type aortoventriculoplasty. There was zero early and late mortality; with mean follow-up of 11.6 years (3-21 years) in the Ross group and 6 years (2-10 years) in the Konno-AVR group. One patient in the Konno-AVR group had reoperation after 2 years for RVOT obstruction. The postoperative echocardiograms of these patients at last follow-up show residual mean gradient across LVOT/AA of 4.4mmHg (2-6mmHg) after RP, and 11.9mmHg (8-17mmHg) after Konno-AVR.

Conclusions: In adults, the "inclusion-cylinder" Ross-procedure is a good alternative for mild to moderate aortic root hypoplasia. However, for cases with severe LVOT obstruction, a Ross-Konno is not possible with the same method of autologous support used in a non-Konno RP, and this could be expected to have an impact on late durability and the need for further intervention, in a group that has already undergone multiple procedures in childhood. Both methods of RP and Konno-AVR lead to excellent early and late results.

Keywords: Konno aortoventriculoplasty; Konno-AVR; Mechanical AVR/Konno operation; Ross/Konno procedure; Severe LVOT obstruction.

MeSH terms

  • Abnormalities, Multiple*
  • Adolescent
  • Adult
  • Aortic Arch Syndromes / diagnosis
  • Aortic Arch Syndromes / surgery*
  • Aortic Valve Stenosis / congenital
  • Aortic Valve Stenosis / diagnosis
  • Aortic Valve Stenosis / surgery*
  • Cardiac Surgical Procedures / methods*
  • Discrete Subaortic Stenosis / congenital
  • Discrete Subaortic Stenosis / surgery*
  • Echocardiography
  • Female
  • Humans
  • Male
  • Middle Aged
  • Retrospective Studies
  • Ventricular Outflow Obstruction / diagnosis
  • Ventricular Outflow Obstruction / surgery*
  • Young Adult