Mitral Disease: The Real Burden for Ross-Konno Procedure in Children

Abstract

Aortic valve replacement and management of complex left ventricular outflow tract obstruction in early life remains a surgical challenge. We assessed our experience with the Ross-Konno procedure. Since 2000, 49 consecutive patients (24 neonates and infants) underwent the Ross-Konno procedure. Anatomic and clinical risk factors were analyzed. Median age was 12.2 months (0.0 to 194.4); 82% had previous valvotomy (surgical, n= 26; balloon, n= 7; balloon then surgical, n= 7) and 35% preceding arch repair (n= 17). Fifteen patients (31%) required concomitant procedures: mitral valve repair (n= 11), replacement (n= 1), endocardial fibroelastosis resection (n= 4), and aortic arch repair (n= 2). There were 5 hospital deaths (10.2%). Median follow-up was 63 ± 47 months. There were 4 late deaths (8.1%), all because ofpersistent pulmonary hypertension despite subsequent mitral procedures. Five-year actuarial survival andfreedom from reoperation were 79.7% ± 6.1% and 68.6% ± 9.3%, respectively. Preoperative lower shortening fraction (p= 0.005) was associated with early mortality, while concomitant mitral surgery and pulmonary hypertension (p= 0.002) were associated with late mortality. Sixteen patients underwent 26 reoperations. Autograft function was normal in 30 of the 37 late survivors (81.1%), 4 (10.8%) had grade 2 regurgitation, and 3 (8.1%) required valve replacement. Ross-Konno in children remains a high-risk procedure. Preoperative ventricular dysfunction is associated with significant early mortality and should favor conservative options. Mitral involvement substantially affects late outcome, survival for these patients relies on the efficacy in relieving mitral disease. Efforts to improve mitral repair in these infants are critically required as an alternative to univentricular pathways.