Konno-Rastan procedure in surgical recurrence of congenital aortic stenosis and hypoplastic aortic annulus

Aortic stenosis (AS) with hypoplastic aortic annulus (HAA), recurrence after percutaneous treatment, progression to severe heart failure, and its association with significant valve insufficiency make it complex and require timely aortic valve surgery [1–3]. The Konno-Rastan (K-R) technique consists of enlarging the aortic ring, and provides an aortic annular area compatible with the current hemodynamic requirement of the patient and its subsequent development [4, 5]. It is currently considered the most effective for widening the aortic ring and the left ventricular outflow tract, constituting an enormous surgical challenge for today’s pediatric cardiac surgeon.
An 11-year-old female patient with a history of severe congenital AS and HAA was initially treated with percutaneous valvuloplasty at 3 years and aortic valve repair with commissurotomy at 6 years. She was admitted to the emergency department of our institution due to symptoms of heart failure and respiratory failure.
The transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) showed a double severe aortic lesion with a predominance of stenosis and recurrent HAA. The mean valve gradient was 76 mm Hg, with aortic annulus of 12 mm, and an aortic root of 18 mm (Figure 1). Likewise, the mitral valve showed severe functional insufficiency with a mitral annulus of 40 mm due to annular dilation secondary to severe growth of the left ventricle (LV) (end-diastolic diameter, 61 mm, Z-score, +4; LV ejection fraction, LVEF, 28%). Due to the clinical status of the patient and the recurrence despite the 2 surgical interventions, the K-R procedure was indicated. The approach was by median re-sternotomy, with extracorporeal circulation (ECC) through central cannulation. A mitral annuloplasty was performed at the level of the posterior leaflet by suturing a band of bovine pericardium using 5-0 polypropylene sutures (Figure 2 A).
Subsequently, an aortotomy with right infundibular ventriculotomy was performed and then the Konno incision (upper third of the interventricular septum) was performed (Figures 2 B, C). The aortic leaflets were resected and a patch of the bovine pericardium was anchored over the upper edge of the Konno incision towards the aortic wall, achieving enlargement of the LV outflow tract (LVOT) (Figure 2 D). After implantation of a mechanical aortic valve prosthesis (19 mm) over the pericardial patch and the neo-annulus (Figures 2 E, F), reconstruction of...


View full text...