Multilevel Left Ventricular Outflow Tract Research Articles

The landscape of congenital heart disease treated with the Ross procedure

BackgroundThe Ross procedure has excellent outcomes in the pediatric population. Some series have reported age- and anatomy-dependent outcomes, but a comprehensive analysis stratified by these variables has not been reported to date. We sought to describe the landscape of congenital heart disease (CHD) treated with the Ross procedure and identify the patients best served by this operation. MethodsOver a total of 30 years, 317 pediatric patients underwent the Ross procedure. These patients were stratified into 4 age groups—neonates (age <31 days; n = 21), infants (age 31 days to 1 year; n = 40), children (age 1-12 years; n = 165), and adolescents (age 13-18 years; n = 91)—and 3 anatomic groups—isolated aortic valve (AV) disease (n = 221), Shone complex or multilevel left ventricular outflow tract (LVOT) obstruction (n = 61), and complex CHD (n = 35). The groups were compared across outcomes. ResultsNeonates and infants had the highest rates of Shone syndrome (P < .001), complex CHD (P < .001), concomitant root enlargement (P < .001), and arch procedures (P < .001). Operative mortality and morbidity were 4.4% (n = 14/317) and 14% (n = 44/317), respectively. Both were higher in neonates and infants (P < .001 for both) but lower for patients with isolated AV disease (P < .001 for both). Ten-year survival and freedom from LVOT reintervention were 92% and 81%, respectively, and were significantly better in patients with isolated AV disease compared to those with complex CHD (P < .001 and P = .005, respectively). In neonates and infants with isolated AV disease, operative mortality was 4% (n = 1/23), morbidity was 9% (n = 2/23), 10-year survival was 85.6%, and 10-year freedom from LVOT reintervention was 88.4%. ConclusionsAmong pediatric patients, those with isolated AV disease are best served with the Ross procedure, regardless of age. Complex CHD is associated with lower survival and increased risk of LVOT reintervention.

Concomitant Aortic Root Replacement With Anterior Konno Annular Enlargement

The need for concomitant aortic annular enlargement and aortic root replacement may be necessary in situations of multilevel left ventricular outflow tract obstruction and/or prior aortic or aortic valve surgery, particularly in the setting of congenital heart disease. It can be extremely tedious and fraught with numerous complications. Major challenges include bleeding in difficult-to-reach areas and the potential need for subsequent operations. This article describes a technique of concomitant aortic annular enlargement and aortic root replacement that minimizes the risk of significant blood loss and facilitates future surgery should it be necessary.

Modified Ross-Konno procedure in children: subcoronary implantation technique with Konno incision for annular and subannular hypoplasia.

The technique of subcoronary autograft implantation for the Ross procedure has shown excellent durability of aortic valve function in adults. However, its use in children with hypoplastic aortic annulus or multilevel left ventricular outflow tract obstruction (LVOTO) was traditionally precluded. We combined this technique with a Konno incision and evaluated LVOTO relief and durability of the autograft function in growing patients. Between January 2012 and January 2017, 13 patients with severe LVOTO and hypoplastic aortic annulus underwent Ross-Konno procedure with subcoronary autograft implantation. The median age at operation was 14 months. Six were infants. Concomitant procedures included resection of endocardial fibroelastosis (n = 9), mitral valvuloplasty (n = 2) and aortic arch repair (n = 1). The Konno incision was enlarged with a patch. The autograft was implanted beneath the ostia of the coronary arteries, retaining external support by the native aortic annulus. A newborn with hypoplastic left heart complex and Turner syndrome died in hospital: early mortality of 7.7%. No residual LVOTO or autograft regurgitation was observed at discharge. At a median follow-up of 20 months, no death had occurred. No catheter or surgical reintervention on the aortic valve or any LVOT site was needed. All peak pressure gradients across the LVOT were <10 mmHg. No autograft regurgitation was detected. The Ross procedure using subcoronary implantation technique combined with LVOT Konno enlargement is feasible even in patients with multilevel LVOTO and marked size discrepancy between the autograft and native aortic annulus. Longer follow-up is indicated to confirm the expected durability of the autograft function.

Twenty-Year Experience with the Konno Operation: A Definitive Option for Multilevel Left Ventricular Outflow Tract Obstruction

Twenty-Year Experience with the Konno Operation: A Definitive Option for Multilevel Left Ventricular Outflow Tract Obstruction

Twenty-year experience with the Ross-Konno procedure.

The Ross-Konno procedure is a last resort for patients with complex multilevel left ventricular outflow tract obstruction (LVOTO) often having other cardiovascular anomalies. It is typically preceded by multiple surgeries. Literature is scarce on long-term follow-up series. Therefore, we have reviewed our 20-year experience with this procedure in order to provide insights in patients' outcomes and to optimize patient selection. Between January 1995 and December 2014, 48 patients underwent the Ross-Konno procedure. The median age at operation was 12.8 months (range, 11 days to 31 years). Twenty-two (46%) patients were under 1 year of age. Forty-four (92%) patients had undergone a total of 82 previous procedures. Eleven (23%) patients had concomitant surgery, predominantly mitral valve (n = 5) and aortic arch surgery (n = 5). The median follow-up time was 4.3 years (range, 0-20 years). There were 6 (12.5%) early deaths and 4 (8.3%) late deaths. Estimated overall survival at 5, 10 and 15 years was 83, 79 and 70%, respectively. Poor LV function was a risk factor for early mortality (odds ratio = 9.5; 95% confidence interval = 1.4-63.7; P = 0.020). Twelve patients required a total of 29 procedures in 17 reoperations. Five patients required reoperation for autograft failure at a median of 14 years (range, 5-15 years) postoperatively. Estimated freedom from all causes of reoperation at 5, 10 and 15 years was 82, 55 and 30%, respectively. All patients had complete and durable relief of LVOTO. At latest follow-up, 5 patients had a sinus of Valsalva Z-score of 5 or greater. One patient had Grade II autograft insufficiency. The Ross-Konno procedure is a durable solution for multilevel LVOTO in a highly complex patient population with high incidence of previous procedures. High early mortality rates in patients with impaired left ventricular function emphasize the importance of patient selection. Freedom from reoperation shows a continuous attrition rate. Reoperation for autograft failure may occur late after the Ross-Konno procedure.

The fate of the neoaortic valve and root following the modified Ross-Konno

In children with aortic valve disease associated with annular hypoplasia or complex multi-level left ventricular outflow tract obstruction (LVOTO), the Ross procedure, combined with a modified Konno-type aortoventriculoplasty is advocated. We aim to examine the fate of the neoaortic apparatus and assess neoaortic valve function following the modified Ross-Konno procedure. Forty-three patients, median age 6 years, underwent modified Ross- Konno with myectomy but without ventricular septal patch utilization. Serial postoperative echocardiograms ( n = 187) were analyzed and regression models adjusted for repeated measures were used to model longitudinal growth of neoaortic annulus and root. There were 2 operative deaths (5%) and 1 late mortality. At 8 years, survival was 93% and freedom from autograft, homograft and all-cause reoperation was 100%, 81%, and 72%, respectively. Median post-procedure diameter and Z-score were 14 mm (7–21 mm), and 1.25 (−3 to +6.1) for neoaortic annulus and 21 mm (9–30 mm) and 1.55 (−1.3 to +4.1) for neoaortic root. Serial echocardiograms showed progressive increase in annular (+0.56 mm/year, p < 0.001) and root (+0.89 mm/year, p < 0.001) diameters but little change in annular (−0.07/year, p = 0.08) and root (−0.002/year, p = 0.96) Z-scores. Nine patients developed autograft regurgitation, however the degree and progression of regurgitation were not significant ( p = 0.22). In children undergoing the modified Ross-Konno procedure, the neoaortic annulus and root increase in size proportionately to somatic growth. Few patients developed autograft regurgitation, usually mild and stable, and none required autograft reoperation. Our findings support the use of modified Ross-Konno as the procedure of choice in children with aortic valve disease and complex LVOTO.

The role of Ross procedure in the management of congenital heart defects

The surgical strategy to manage multilevel left ventricular outflow tract diseases is changing constantly, however, the Ross-procedure has remained a standard method for 45 years. The aim of the study was to analyze early and mid-term results of Ross-procedure in congenital heart defects (single surgeon's results). From 2001 until 2011 a total of 63 patients (age, 28 days-21 years; mean: 10 years, weight 3.4-96 kg; mean, 8.8 kg) underwent Ross (n = 40), Ross-Konno (n = 17) or Ross-Konno-mitral (n = 6) procedures. Indication for Ross procedure was aortic regurgitation in 15 patients (associated with ventricular septum defect in 8 patients) and a predominant aortic stenosis in 25 patients. 17 patients with severe left ventricular outflow tract obstruction underwent Ross-Konno procedure. 6 patients with concomitant mitral valve disease (Shone syndrome, 3 patients; complete atrioventricular septal defect, 3 patients) were reconstructed by Ross-Konno-mitral valve procedure. Among Ross patients there were one early (cerebral complication) and one late death (homograft endocarditis) with a mean follow-up time of 7.4±1.8 years. Because of an early autograft endocarditis a 3-year-old boy underwent homograft implantation and was treated successfully with Bentall-procedure 9 years later. One patient with autograft regurgitation is waiting for reoperation. Among Ross-Konno patients there was no early or late death, and none of the patients underwent reoperation. In Ross-Konno-mitral patients there was one early death (28-day-old boy) and during a mean follow-up time of 2.5±1 years, and no reintervention or reoperation was needed in 5 patients. The results indicate a good outcome of Ross-, Ross-Konno-, Ross-Konno-mitral procedures in patients with congenital heart defects when surgery is performed by a highly experienced heart surgeon. In newborns, infants and small children Ross- and Ross-Konno procedures are the only methods for managing left ventricular outflow tract diseases. Concomitant severe mitral disease adds a high level of technical complexity to the Ross-Konno/mitral procedure, but it should be balanced against alternative strategies (eg. single ventricle palliation or transplantation).

The fate of the neoaortic valve and root after the modified Ross–Konno procedure

In children with aortic valve disease associated with annular hypoplasia or complex multilevel left ventricular outflow tract obstruction, the Ross procedure, combined with a modified Konno-type aortoventriculoplasty, is advocated. We aim to examine the fate of the neoaortic apparatus and assess neoaortic valve function after the modified Ross-Konno procedure. Forty-three patients, with a median age of 6 years, underwent the modified Ross-Konno procedure with a myectomy but without the use of a ventricular septal patch. Serial postoperative echocardiograms (n = 187) were analyzed, and regression models adjusted for repeated measures were used to model the longitudinal growth of the neoaortic annulus and root. There were 2 operative deaths (5%) and 1 late mortality. At 8 years, survival was 93% and freedom from autograft, homograft, and all-cause reoperation was 100%, 81%, and 72%, respectively. The median postprocedure diameter and z score were 14 mm (7-21 mm) and +1.3 (-3.0 to +6.1) for the neoaortic annulus and 21 mm (9-30 mm) and +1.6 (-1.3 to +4.1) for the neoaortic root, respectively. Serial echocardiograms showed a progressive increase in annular (+0.56 mm/year, P < .001) and root (+0.89 mm/year, P < .001) diameters but little change in annular (-0.07/year, P = .08) and root (-0.002/year, P = .96) z scores. Autograft regurgitation developed in 9 patients; however, the degree and progression of regurgitation over time were not significant (P = .22). After the modified Ross-Konno procedure, the neoaortic annulus and root increased in size proportionately to somatic growth. Autograft regurgitation, usually mild and stable, developed in few patients, and none required autograft reoperation. Our findings support the use of the modified Ross-Konno as the procedure of choice in children with aortic valve disease and complex left ventricular outflow tract obstruction.

Ross-Konno Procedure With Mitral Valve Surgery

The Ross-Konno procedure has emerged as a complex procedure to address multilevel left ventricular outflow tract obstruction in infants and small children. Significant proportions of patients, however, have concomitant mitral valve disease and require a mitral procedure in addition to the Ross-Konno procedure. Ross-Konno-mitral surgery puts three valves at risk and may be associated with significant morbidity and mortality and, therefore, we sought to characterize midterm clinical outcomes after the Ross-Konno procedures with and without concomitant mitral valve surgery. We reviewed medical records of 20 consecutive patients who underwent Ross-Konno/Mitral procedures (n = 8) or Ross-Konno-nonmitral procedures (eg, without mitral valve repair, n = 12) between 1995 and 2007. In Ross-Konno mitral patients (age 326 +/- 268 days; range, 1 to 817 days), there were 3 early deaths and 1 late death with a mean follow-up of 1.8 +/- 2.5 years. Seven patients had intervention prior to Ross-Konno. Actuarial survival at 5 years was 43.8%. In Ross-Konno nonmitral patients (age, 2,110 +/- 2,020 days; range, 3 to 5,563 days), there was one early death with mean follow-up of 2.7 +/- 2.6 years. Ten patients had intervention prior to Ross-Konno. Actuarial survival at 5 years was 91.7%. There were significant differences between groups in age, survival rate, intubation time, coronary care unit stay, and hospital stay (Ross-Konno mitral vs Ross-Konno nonmitral: 0.89 +/- 0.73 vs 5.8 +/- 5.5 years, 43.8 vs 91.7%, 17.0 +/- 15.7 vs 2.6 +/- 2.7 days, 22.9 +/- 22.7 vs 4.1 +/- 3.1 days and 28.6 +/- 21.2 vs 11.5 +/- 7.1 days). The Ross-Konno procedure effectively treats multilevel left ventricular outflow tract obstruction in infants and small children. The requirement for concomitant mitral valve surgery, however, is associated with significantly higher likelihood of mortality.

Midterm Results of Ross Aortic Valve Replacement: A Single-Institution Experience

We reviewed our institutional midterm experience to assess autograft and homograft hemodynamics and reoperative frequency after Ross aortic valve replacement. Between June 1993 and January 2009, 212 consecutive patients (mean age, 24.8 +/- 15.5 years; range, 1 month to 67 years) underwent Ross aortic valve replacement; 49% were younger than 19 years old. One hundred forty-two additional procedures were required in 101 of the 212 patients (48%) at the time of the Ross aortic valve replacement. One hundred ninety-three patients had isolated aortic valve disease, and 19 pediatric patients had more complex, multilevel left ventricular outflow tract obstruction. There were 2 early (1%) and 2 late deaths (1%), with a mean follow-up of 7.9 +/- 4.2 years (range, 1 month to 15 years). Actuarial survival at 15 years was 98%. To date 28 patients (13%) have required reoperation. At 15 years, freedom from autograft sinus or ascending aortic dilatation was 79%, autograft dysfunction, 91%, autograft reoperation, 89%, and autograft replacement, 96%. Freedom from pulmonary allograft replacement was 96% at 15 years. The Ross aortic valve replacement can be performed in children and adults with good midterm results. The late complications of autograft regurgitation, sinus or ascending aortic dilatation, can usually be corrected with a valve-sparing root replacement. These complications can often be prevented by (1) aggressive treatment of postoperative systemic hypertension, (2) replacement of a dilated ascending aorta at the initial Ross procedure, or (3) external fixation of the autograft annulus or sinotubular junction. The potential of late autograft insufficiency, ascending aortic and sinus dilatation, or homograft stenosis and insufficiency warrants annual follow-up.

Ross-Konno operation in children

The Ross-Konno procedure is an excellent technique for the treatment of complex multilevel left ventricular outflow tract obstruction with severe annular hypoplasia and a dysplastic aortic valve. The operation can be performed earlier in life, thus avoiding repeated surgical reinterventions, which may provide only short-term palliation and potentially exacerbate ventricular function. The Ross-Konno procedure increases our therapeutic choices for neonates or infants with critical aortic stenosis, who show unacceptable results following open valvotomy or balloon valvotomy. The pulmonary autograft demonstrates durability without the likelihood of developing aortic stenosis or progressive dilatation and a low incidence of developing aortic insufficiency. Despite the technically demanding nature of the operation, the Ross-Konno procedure is the method of choice for the multilevel type of left ventricle outflow tract obstruction, especially in newborns and infants.

Long-term results of the Konno procedure for complex left ventricular outflow tract obstruction

This study was undertaken to determine long-term clinical and echocardiographic outcomes after the Konno procedure. Fifty-three patients who underwent the Konno procedure between January 1, 1980, and January 1, 2004, were reviewed. Mean age at operation was 19 years (range, 1-65 years). Indications were as follows: complex subaortic or tunnel stenosis in 22 (41%), multilevel left ventricular outflow tract obstruction in 20 (38%), and aortic valve stenosis or hypoplasia in 11 (21%). Before the Konno procedure, 66 operations were performed in 41 (77%) patients. Thirty-three (62%) patients had greater than New York Heart Association class I symptoms preoperatively. A mechanical aortic valve was implanted in 40 (75%), a homograft in 10 (19%), and a xenograft prosthesis in 3 (6%). Mortality at 30 days was 8% (n = 4). Survival at 10 years was 86%. Risk factors for overall mortality were New York Heart Association class (hazard ratio 2.22, P = .04) and longer bypass time (hazard ratio 1.93/hour, P = .04). The cumulative probability of aortic valve reoperation was 19% at 5 years and 39% at 10 years, occurring in 15 patients at a median of 3.8 years. The average left ventricular outflow tract mean gradients were 19 mm Hg at 1 year (n = 9), 13 mm Hg at 1 to 3 years (n = 9), and 13 mm Hg at 3 to 5 years (n = 5). Pulmonary regurgitation was detected in 6 patients. Pulmonary valve replacement was performed in 3 (6%). At the date of last contact, all patients for whom data was available were in New York Heart Association functional class I or II. The Konno procedure is effective, allowing both long-term reduction of left ventricular outflow tract obstruction and improvement in functional class. Prosthetic aortic valve and native pulmonary valve complications may necessitate reoperation.

The Ross-Konno Procedure in Children: Outcomes, Autograft and Allograft Function, and Reoperations

The Ross aortic valve replacement with a modified Konno-type enlargement Ross-Konno procedure of the aortic annulus and subannular region allows an autograft aortic valve replacement for children with significant annular and subannular hypoplasia. The potential for growth and the proven durability of the autograft make the Ross-Konno procedure an ideal aortic valve replacement for this subgroup with multilevel left ventricular outflow tract obstruction. We reviewed our institutional midterm experience to assess autograft and homograft hemodynamics, and management after a Ross-Konno procedure. Between 1995 and 2005, 14 consecutive children (mean age, 6.4 +/- 5.9 years; range, 1 month to 17 years) underwent the Ross-Konno procedure. All children had severe to critical aortic stenosis or multilevel left ventricular outflow tract obstruction. There was 1 early and 1 late death with a mean follow-up of 5.7 +/- 3.6 years. Actuarial survival at 10 years was 86%. Three patients underwent right ventricular outflow tract reoperation for conduit replacement for homograft dysfunction and one patient required redo aortic root replacement with a mechanical valves for progressive aortic insufficiency. Freedom from right ventricular outflow tract and autograft reoperation at 10 years is 77% and 92%, respectively. Aortic annular dilation was not observed in all patients. Univariate and multivariate analysis identified no risk factors for autograft or homograft valve-related reoperation. The Ross-Konno procedure is an excellent technique to treat complex multilevel left ventricular outflow tract obstruction in children with significant annular and subannular hypoplasia. The autograft demonstrated durability without development of aortic stenosis or progressive dilation and a low incidence of developing progressive aortic insufficiency. Enlargement of the aortic annulus appear to parallel somatic growth in most instances.

Invited commentary

Multilevel left ventricular outflow tract obstruction may be due to valvular and subvalvular aortic stenosis. Subvalvular stenosis has a tunnel-like fibromuscular component, which may vary in exact location as well as in degree of obstruction. A Ross-Konno procedure can adequately deal with this problem, as the ultimate goal is to restore normal physiology and preserve left ventricular function. This situation is different from valvular aortic stenosis, in which a Ross-Konno procedure is done for annular enlargement to accommodate a large pulmonary autograft and the same ultimate goal.

Long-term results of surgical repair in patients with congenital subaortic stenosis

The aim of the study was to analyze the long-term results of congenital subvalvar aortic stenosis (SAS) relief and the risk factors associated with recurrence and reoperations. Between January 1960 and March 2005, 190 patients underwent surgical correction for discrete (n=140) and tunnel (n=50) congenital subaortic stenosis. There were 115 male and 75 female patients ranging in age from 1 week to 36 years (mean age, 8.2+/-4.4 years). Preoperatively, 133 patients were in NYHA functional class I or II, 57 in class III or IV. There were several initial surgical procedures performed in patients with congenital subaortic stenosis: fibrous or fibromuscular subaortic resection, apical aortic conduit insertion, aortic valve replacement with mechanical valve, Ross and/or Konno procedure. There were 7 early (4%) and 10 late (5%) deaths. Actuarial survival including operative mortality of patients with discrete and tunnel SAS was 94% and 84% at 40 years (P=0.14), respectively. Within 7.1+/-6.2 years a recurrent peak aortic gradient >50 mmHg and moderate to severe aortic insufficiency were found in 50 patients (28%), all of whom had 104 reoperations. At late follow-up, ranging from 6 months to 42 years (mean 9.6+/-7.5 years), the left ventricle-aorta gradient was higher in patients with tunnel versus discrete obstruction (28+/-11 mmHg vs. 13+/-9 mmHg; P=0.01) with a 40-year poor freedom from reoperation (14% vs. 89%; P<0.001). Patients with tunnel SAS and complex multilevel left ventricular outflow tract obstruction required higher reoperation rates. Aortic valve replacement with pulmonary autograft (Ross procedure) performed at our institution resulted in low mortality and morbidity.

Long-Term Results of Apical Aortic Conduits in Children With Complex Left Ventricular Outflow Tract Obstruction

Apical aortic conduits were used in children with complex left ventricular outflow tract obstruction at our institution before we adopted the Ross and Ross-Konno procedures. The early results with apical aortic conduits were quite good when we used a porcine xenograft conduit and were less satisfactory when we converted to an aortic homograft valve as the conduit valve. This report summarizes our clinical experience with apical aortic conduits in children with an emphasis on hemodynamic results, reoperation, and long-term follow-up. Records of 28 patients (age range, 2 weeks to 19 years) who underwent insertion of apical aortic conduit between September 1979 and June 1993 were reviewed. All patients had complex multilevel left ventricular outflow tract obstruction. All were symptomatic, and 22 (79%) had had one or two previous aortic valvotomies or left ventricular outflow tract operations, or both. Hospital mortality was 11% (3 of 28). Twenty-five children survived the perioperative period and improved, and 21 have had one or more cardiac catheterization from 6 to 18 months (mean, 1.2 years) after the initial operation. Reduction or resolution of resting mean left ventricular-to-aortic peak gradient in the early postoperative period from 81.8 +/- 24.0 to 15.4 +/- 8.9 mm Hg was demonstrated (p < 0.001). Overall 25-year survival was 57%. Fourteen surviving patients (56%) have undergone subsequent procedures (n = 18) from 5 months to 16 years postoperatively (mean, 6.9 years) because they developed a recurrent left ventricular-to-aortic gradient of 58 +/- 28 mm Hg (p < 0.002). One patient underwent heart transplantation. All other late survivors have normal left ventricular function as determined by serial echocardiography. Apical aortic conduit is effective in relieving complex left ventricular outflow tract obstruction and improving left ventricular performance with acceptable short-term and midterm results, but late complications caused primarily by conduit tissue valve dysfunction are frequent in children. Since the early 1990s, the apical aortic conduit procedure has been largely replaced with the Ross or Ross-Konno procedure in our pediatric practice.

Konno aortoventriculoplasty in children and adolescents: from prosthetic valves to the ross operation

Background. In children with complex multilevel left ventricular outflow tract obstruction (LVOTO), the Konno aortoventriculoplasty is used to enlarge the aortic root and increase the size of the aortic valve implanted. We present our experience with the evolution of this surgical approach from prosthetic valves to the Ross operation. Methods. Between March 1982 and July 2000, 60 patients (36 males and 24 females) had 72 Konno aortoventriculoplasties (prosthetic valve and Konno group [57 patients; redo, 12] and Ross-Konno group [15 patients]). The patients’ ages ranged from 5 days to 18 years (mean, 8.2 years). The underlying anatomic diagnoses were congenital aortic stenosis and LVOTO in 51 patients, coarctation of the aorta with bicuspid aortic valve in 13, severe aortic insufficiency associated with a ventricular septal defect in 8, interrupted aortic arch in 6, mitral stenosis in 6, atrioventricular septal defect in 5, and endocarditis in 3. There was no statistical difference in age or diagnosis between the two groups. The prosthetic valve group included 42 mechanical valves, 9 homografts, and 6 xenografts. Results. Follow-up ranged from 10 months to 18.5 years (mean, 9.7 years) in the prosthetic valve and Konno group compared with 5 months to 3.7 years (mean, 2.1 years) in the Ross-Konno group ( p < 0.05). There were 10 early deaths and four late deaths in the prosthetic valve and Konno group as compared with one early death and two late deaths in the Ross-Konno group ( p = not significant). Reoperations for LVOTO and aortic valve replacement were significantly higher in the prosthetic valve and Konno group as opposed to the Ross-Konno group (16 vs 0, p < 0.05) mainly because of the biological valve and Konno subgroup. There were no statistical differences in reexploration for bleeding, pacemaker insertion, and reoperations for indications other than LVOTO and aortic valve replacement between the two groups. Conclusions. The Konno aortoventriculoplasty is a good surgical option for complex LVOTO. Patients with a prosthetic valve and Konno carry a high rate of reoperation. Early operative results with the Ross-Konno operation seem promising.

Extended aortic root replacement with pulmonary autografts: Experience in 14 cases

The surgical relief of complex multilevel left ventricular outflow tract obstruction remains a challenging problem. We present a new operation that combines the concepts of aortoventriculoplasty, extended aortic root replacement, and the use of a pulmonary autograft. Fourteen patients underwent this operation: 9 patients after previous attempts to relieve diffuse subvalvular stenosis and 5 patients who had excessive gradients over an outgrown aortic valve prosthesis. All patients except 1 survived the operation. Complete heart block developed in 1 patient after a septal infarction. One patient remained in congestive heart failure and died suddenly after 17 months. All other patients are in New York Heart Association class I after a mean follow-up of 20 +/- 12 months. All patients showed excellent function of the autograft and homograft valve at follow-up. This operation might present a more durable or even a definitive solution in the management of these complex left ventricular outflow tract obstructions.

Radical aortic root enlargement in the infant and child.

Complex multilevel left ventricular outflow tract obstruction includes some of the more challenging problems in congenital cardiac reconstructive surgery. Preoperative studies must carefully delineate the level of obstruction that may be entirely below the aortic annulus (i.e., subaortic stenosis), at the level of the aortic annulus (i.e., aortic annular hypoplasia), may be related to valve leaflet obstruction due to rigid or fused valve leaflets (i.e., aortic valve stenosis), or may be at the level of the tips of the commissures of the aortic valve (i.e., supravalvar aortic stenosis). Frequently, variable contributions are present from all these potential levels of obstruction. An important underlying goal in planning surgical therapy should be preservation of the child's own aortic valve, whenever possible. Operative procedures should preserve growth potential and minimize the need for repeat surgical procedures. A number of surgical options that incorporate these goals will be described.