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Konno Procedure (anterior aortic annular enlargement) for Mechanical Aortic Valve Replacement

  • Hiromi Kurosawa
    Correspondence
    Address reprint requests to Hiromi Kurosawa, MD, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
    Affiliations
    From the Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan
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      Aortic annular enlargement is frequently necessary for the young patient with a small aortic annulus undergoing mechanical valve replacement. The Konno procedure was introduced to allow aortic valve replacement with an adequate sized mechanical valve for patients with a small aortic annulus.
      • Konno S
      • Imai Y
      • Lida Y
      • et al.
      A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring.
      A heart with concordant atrioventricular and ventrieu-loarterial relation has an anatomical benefit whereby the left ventricular outflow tract makes a right angle with the right ventricular outflow tract. Therefore, a longitudinal incision in the aortic root and a transverse incision in the right ventricular outflow tract make a straight line. When an aortic valve replacement is necessary in combination with annular enlargement the Konno proceilure is the surgery of choice.
      Using standard cardiopulmonary bypass with moderate hypothermia and antegrade and/or retrograde cold cardioplegia, the aortic valve is inspected through a longitudinal incision in the aortic wall. If the valve is not repairable, it is excised for valve replacement and the annular size is measured.

      Surgical Technique

      Figure thumbnail fx1
      1If the annular size is too small for an adequate size prosthetic valve, the longitudinal incision is anteriorly extended from the right coronary sinus to the right ventricular outflow tract. The incision is just to the right of the anterior commissure of the aortic valve and is remote from the right coronary orifice.
      Figure thumbnail fx2
      2A longitudinal incision is extended towards the aortoventricular junction on the anterior wall of the ascending aorta. A transverse incision is placed on the free wall of the right ventricular outflow tract beneath the pulmonary valve. Both incisions meet in a straight line at the aortoventricular junction.
      Figure thumbnail fx3
      3The ventriculoinfundibular fold and the aortic annulus are incised between the aortic wall incision and the right ventricular free wall incision. The incision is extended into the infundibular septum 5 to 7 mm underneath the pulmonary valve.
      Figure thumbnail fx4
      4The Konno incision is 2 to 3 mm to the right of the anterior commissure of the aortic valve and remote from the right coronary orifice. After the infundilbular septum is incised, a large enough sizer can be inserted into the enlarged left ventricular outflow tract. Because the infundibular septum incision is extended only to the middle of the infundibular septum and does not reach to the anterior septum, damage to the first septal branch of the left anterior descending coronary artery should be prevented.
      Figure thumbnail fx5
      5The incised ventricular septum is usually two layers and thick. The first pledgeted suture is transmurally placed through the thick ventricular septum from left to right at the end of the infundibular septal incision ().
      All pledgeted sutures along the incised ventricular septum are transmurally stitched through the thick septum from the left ventricular side to the right (). Thus, all pledgets are located on the left side of the septum. A transitional suture is placed at the junction of the infundibular ventricular septum, the ventriculoinfundibular fold and the aortic wall.
      Figure thumbnail fx6
      6A composite patch made of Dacron (DuPont, Wilmington, DE) and preserved xenopericardium is used for aortoventriculoplasty. All transmural pledgeted sutures are passed through the patch and tied. The ventricular part of the aorto-ventriculoplasty patch is fitted on the ventricular septal incision. Then a continuous suture reinforces the interrupted pledgeted sutures of the ventriculoplasty patch.
      Figure thumbnail fx7
      7At the beginning of the sutures for aortic valve replacement, one needle of transitional suture (#1 in ) from the aortic annulus to the patch is passed sequentially through the aortic annulus, the ventricular septum and the patch at the junction of the ventricular septum and the aortic annulus (). This needle is then passed through the patch from outside to inside. The second suture is passed through the aortic annulus and the third suture is passed through the patch.
      Figure thumbnail fx8
      8All sutures are stitched through the aortic annulus or the patch. Two transitional sutures from the junction between the aortic annulus and the ventricular septum to the patch are placed as well. Pledgeted sutures along the aortic annulus are placed in the usual fashion for aortic valve replacement.
      Figure thumbnail fx9
      9A bi-leaflet mechanical valve is inserted in the enlarged aortic annulus and the sutures along the aortic annulus are tied.
      Figure thumbnail fx10
      10The fact that one-third of the valve annulus is sutured to the patch indicates 1.5 times enlargement of the aortic annulus. All sutures are tied and valve replacement is Finished at the enlarged aortic annulus.
      Figure thumbnail fx11
      11The aorto-ventriculoplasty patch bulges because of the large mechanical valve ().
      Figure thumbnail fx12
      12A transitional suture is stitched through the ventriculoinfundibular fold, aortic wall, and patch ().
      During this suture, a pledget is placed on the right ventricular side of the ventriculoinfundibular fold. A composite patch is sutured with the aortic wall by running suture ().
      Figure thumbnail fx13
      13A right ventricular patch is trimmed in the shape of a crescent. The suture line of the right ventricular patch is distal to the suture line of the mechanical valve on the aorto-ventriculoplasty patch. The right ventricular patch is sutured with the aorto-ventriculoplasty patch and then with the free wall of the right ventricular outflow tract by running suture.
      Figure thumbnail fx14
      14The Konno procedure is now complete.

      Comments

      After the Ross procedure
      • Ross DN
      • Jackson M
      • Davis J
      Pulmonary autograft aortic valve replacement: Long term results.
      was revived in the 1980s and aortic and pulmonary homografts became available, the Ross procedure evolved to be the procedure of choice for young patients who need aortic valve replacement with annular enlargement. Therefore, the classic Konno procedure is not usually the procedure of first choice for aortic annular enlargement in children. However, on occasion, homografts may be unavailable for right ventricular tract reconstruction. Another situation where the classic Konno procedure may be preferred is in the patient who has previously undergone closure of a subarterial ventricular septal defect close to the pulmonary annulus. Under these circumstances the pulmonary valve may not be suitable for use in a Ross procedure.
      The concept of the Konno procedure in which the left ventricular outflow tract is enlarged by an incision from the aortic root into the left ventricular outflow tract has been applied in conjunction with the Ross procedure and has been called the Ross-Konno procedure.
      • Reddy VM
      • Rajasinghe HA
      • Teitel DF
      • Haas GS
      • Hanley FL
      Aortoventriculoplasty with the pylmonary autograft: The “Ross-Konno” procedure.
      The Konno aortoventriculoplasty has been reported to be a good surgical option for complex left ventricular outflow tract obstruction. Freedom from reoperation for the mechanical valve has been reported as 80% at 10 years and 52% at 15 years. In the experience of the Heart Institute of Japan, 60 patients underwent a Konno procedure with a mechanical valve between May 1984 and December 2000. The ages ranged from 2 to 37 years old with an average age of 11.6 years. There were no hospital deaths with five late deaths. There have been only two reoperations.

      References

        • Konno S
        • Imai Y
        • Lida Y
        • et al.
        A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring.
        J Thorac Cardiovasc Surg. 1975; 70: 909-917
        • Ross DN
        • Jackson M
        • Davis J
        Pulmonary autograft aortic valve replacement: Long term results.
        J Card Surg. 1991; 6: 529-533
        • Reddy VM
        • Rajasinghe HA
        • Teitel DF
        • Haas GS
        • Hanley FL
        Aortoventriculoplasty with the pylmonary autograft: The “Ross-Konno” procedure.
        J Thorac Cardiovasc Surg. 1996; 111: 158-167
        • Erez E
        • Kanter KR
        • Tam VKH
        • Williams WH
        Konno aortoventriculoplasty in children and adolescents: From prosthetic valves to the Ross operation.
        Ann Thorac Surg. 2000; 74: 122-126