Surgical relief of left ventricular outflow tract obstruction in adults with congenital aortic stenosis and associated aortic annulus hypoplasia and/or subaortic obstruction

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, 17 adults of mean age 34.9 years (18 - 57) with hypoplastic aortic annulus (AA) measuring 20 mm or less, and mean aortic valve/LVOT gradient of 61 mm Hg (30 - 70) presented for surgery. Results: 8 patients with mean LVOT/AA diameter 19.6 mm (18 - 20) underwent an inclusion cylinder type Ross procedure (RP). 9 patients with more severe LVOT/AA obstruction, mean diameter of LVOT/AA of 17.4 mm (16 - 19) underwent mechanical aortic valve replacement (AVR) with standard Konno type aortoventriculoplasty. There was zero early and late mortality, no re-operations were required, with mean follow up of 7.6 years (1 - 20). Last echo shows residual mean gradient across LVOT/AA of 6 mm Hg (2 - 12) after RP, and 13.2 mm (6 - 22) after mechanical AVR/Konno. Summary: In adults, the RP is a good alternative for mild to moderate aortic root hypoplasia, however for cases with severe 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 impact on late durability and the need for further intervention, in a group that have already undergone multiple procedures in childhood. Both methods lead to excellent early and late results.