Modified-Bentall Single-Patch Konno Enlargement Technique for Aortic Stenosis and Prosthesis-Patient Mismatch.

Abstract

Aortic stenosis and prosthesis-patient mismatch complicate surgery for patients with small left ventricular outflow tracts. We present outcomes of a modified-Bentall single-patch Konno enlargement (BeSPoKE) technique for complex left ventricular outflow tract obstruction in adults. The BeSPoKE technique facilitates a true outflow tract enlargement via an anterior septo-ventriculoplasty, using a single pericardial patch, followed by composite aortic valve-graft root replacement. Postoperative outflow tract geometry and valvular physiology were compared to preoperative measurements using echocardiography and computed tomographic angiography; two-year clinical outcomes were assessed. From October 2017 to March 2022, 25 adults (median age 60 years; 84% female) underwent a BeSPoKE repair. Mean preoperative aortic valve gradient was 44 ± 19mmHg. Twenty-one (84%) patients had previous aortic valve replacements with prosthesis-patient mismatch; median implant size preoperatively was 19mm. Postoperatively, all patients received a prosthesis of at least 21mm, with a median upsizing of 2 (15th-85th Percentile, 2-3 sizes). Mean postoperative aortic valve gradient was 8.5 ± 4.1mmHg (P<.001); mean 2-year gradient was 8.3 ± 1.3mmHg. All patients with bioprosthetic replacements qualified for future transcatheter valve replacements. Postoperative complications included atrial fibrillation (9; 36%) and complete heart block requiring pacemaker placement (8; 32%). There were zero operative mortalities and no reoperations reported. There were 2 late non-cardiac-related deaths; 2-year survival was 92%. The modified-Bentall single-patch Konno enlargement technique facilitates larger prosthesis placement, improves hemodynamics, and enables future transcatheter reinterventions. This approach is a safe treatment for complex left ventricular outflow tract obstruction and prosthesis-patient mismatch in adults.