Ann Thorac Surg 2004;78:1854-1855
© 2004 The Society of Thoracic Surgeons
How to do it
Konno Procedure Using Atrioventricular Groove Patch Plasty After Arterial Switch Operation
Yoshimichi Kosaka, MDa,
Hiromi Kurosawa, MDa,*,
Masayoshi Nagatsu, MDa
a Department of Cardiovascular Surgery, Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan
Accepted for publication August 28, 2003.
* Address reprint requests to Dr Kurosawa, Department of Cardiovascular Surgery, Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
kurosawa{at}hij.twmu.ac.jp
 |
Abstract
|
|---|
A patient with transposition of the great arteries accompanied by Shaher type 9 coronary anatomy experienced the development of progressive neoaortic valvular regurgitation with a small annulus, supravalvular stenosis, and neopulmonary valvular and supravalvular stenoses 15 years after an arterial switch operation. To implant a prosthetic valve clinically adequate in size, the Konno procedure was necessary. However, the right coronary anatomy precluded the original Konno procedure. My colleagues and I accomplished neoaortic anterior annular enlargement in this case by using atrioventricular groove patch plasty without jeopardizing the right coronary artery, and this resulted in a satisfactory outcome.
|
Introduction
|
|---|
A female infant with transposition of the great arteries and ventricular septal defect underwent an arterial switch operation (ASO) at 7 months of age without any major complication. Neoaortic valvular regurgitation without annular dilatation was recognized from 5 years after ASO. By the time the patient was aged 16 years, it had progressed to more than a moderate degree, and, in addition, marked progression of supravalvular neoaortic stenosis was noted. The diameters of the neoaortic annulus and supravalvular stenosis were less than 19 mm, so an annular enlargement procedure was necessary. Of note, the coronary anatomy in this case was Shaher type 9 after ASO (Fig 1). The anatomy of the right coronary artery, which originated from the left facing sinus and traversed the surface of the right ventricular outflow tract under the neopulmonary annulus, precluded the original Konno procedure.
View larger version (1K):
[in this window]
[in a new window]
|
Fig 1. Schematic drawing of coronary anatomy, Shaher type 9, after arterial switch operation [4]. Arrows indicate the directions of annular enlargement as an application of atrioventricular groove patch plasty [5]. Note that the anatomy of the right coronary artery, originating from the left facing sinus and traversing the right ventricular outflow tract below the neopulmonary annulus, precluded the original Konno ventriculotomy.
|
|
|
Technique
|
|---|
Under cardiopulmonary bypass, the neopulmonary artery was transected and a longitudinal incision was made in the narrowed ascending aorta. A 19-mm sizer could not be passed through the aortic incision. The incision was further extended across the small neoaortic annulus between the coronary arteries and downward into the infundibular septum, preserving adequate suture margins beneath both coronary ostia. The neopulmonary annulus was incised between the right and left facing cusps, and its incision was connected to the aortoventriculotomy. The neopulmonary nonfacing cusp was incised to relieve the prior valvular stenosis and to create a consequent bulge for the forthcoming shelf due to the large implanted prosthetic valve in the neoaortic annular position. The incision was extended toward and along the right atrioventricular groove between the right coronary artery and the tricuspid annulus, thus preserving a suture margin. A composite patch made of Dacron (DuPont, Wilmington, DE) and xenopericardium was used for aortoventriculoplasty, with an adequate width to implant a 23-mm bioprosthetic valve and to reconstruct the neoaortic root (Fig 2A). Right ventricular outflow tract reconstruction was performed by using a xenopericardial patch bearing a polytetrafluoroethylene valve [1] (Fig 2B).
View larger version (79K):
[in this window]
[in a new window]
|
Fig 2. Surgical procedure. (A) The pulmonary trunk was transected. Vertical aortoventriculotomy was performed, followed by a right ventricular incision across the neopulmonary nonfacing cusp toward the atrioventricular groove, avoiding injury of the right coronary artery. Right and left facing neopulmonary cusps were preserved. A 23-mm bioprosthetic aortic valve was implanted in the annular position. A xenopericardial patch was used to augment the aortoventriculotomy. (B) Right ventricular outflow tract reconstruction was performed with a xenopericardial patch bearing a polytetrafluoroethylene valve. The posterior wall of the pulmonary trunk was reconstructed by using an aortoventricular augmentation patch.
|
|
|
Comment
|
|---|
Progressive neoaortic valvular regurgitation with a small annulus is a rare but important late complication after ASO. In this case, supravalvular aortic stenosis and a small aortic annulus less than 19 mm in diameter necessitated an annular enlargement technique such as the Konno procedure [2, 3]. However, the Shaher type 9 coronary anatomy and anteroposterior relationship of the great arteries precluded the original Konno procedure because the right coronary artery coursed across its incision line in the right ventricular free wall [4]. As shown in this case, vertical extension of the aortoventriculotomy to the infundibular septum and neopulmonary annulus and simultaneous application of atrioventricular groove patch plasty [5] afforded neoaortic anterior annular enlargement, subsequent implantation of an adequate prosthetic valve (23 mm in diameter), and simultaneous relief of supravalvular neoaortic and right ventricular outflow tract stenoses without jeopardizing the right coronary artery.
It is reported that neoaortic valvular regurgitation tends to progress for more than 6 years after ASO [6], and the demand for neoaortic valve operation after ASO will increase in the future. My colleagues and I believe that anterior aortic annular enlargement with atrioventricular groove patch plasty [5], described here as a modification of the Konno procedure [2, 3], could become a surgical option for neoaortic root disease after ASO associated with a small aortic annulus and complex coronary anatomy, such as Shaher type 9.
|
References
|
|---|
- Yamagishi M, Kurosawa H. Outflow reconstruction of tetralogy of Fallot utilizing a Gore-Tex valve. Ann Thorac Surg. 1993;56:1414–1416[Abstract]
- Konno S, Imai Y, Iida Y. A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring. J Thorac Cardiovasc Surg. 1975;70:909–917[Abstract]
- Kurosawa H. Konno procedure (anterior aortic annular enlargement) for mechanical aortic valve replacement. Op Tech Thorac Cardiovasc Surg. 2002;7:188–194
- Kurosawa H, Imai Y, Takanashi Y, et al. Infundibular septum and coronary anatomy in Jatene operation. J Thorac Cardiovasc Surg. 1986;91:572–583[Abstract]
- Morita K, Kurosawa H, Koyanagi K, et al. Atrioventricular groove patch plasty for anatomically corrected malposition of the great arteries. J Thorac Cardiovasc Surg. 2001;122:872–878[Abstract/Free Full Text]
- Haas F, Wottke M, Poppert H, Meisner H. Long-term survival and functional follow-up in patients after the arterial switch operation. Ann Thorac Surg. 1999;68:1692–1697[Abstract/Free Full Text]
Top
Abstract
Introduction
