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Ann Thorac Surg 2006;82:1307
© 2006 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, Thoraxcentre, Bd 555, Dr Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands
(Email: a.j.j.c.bogers{at}erasmusmc.nl).
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. The differences are particularly relevant to the residual muscle rim on the autograft, particularly in the area of the anterior lip.
If we are to generate experience and knowledge from a small series, precise pathologic diagnoses are important, because both short-term and long-term outcomes depend on these details. Unfortunately, Brown and colleagues [1] omit needed information in the initial diagnosis in this series. Therefore, the initial defect, which is qualitatively described as critical aortic valvular or multilevel stenosis, cannot be correlated with the actual condition of the valvular and subvalular defects at the time of the Ross-Konno procedure, when 7 out of 14 children already had aortic regurgitation. Probable differences in initial and secondary presentations are further documented by the wide age range (1–17 years) at the Ross-Konno procedure. Thus, the duration of follow-up is limited to a mean of 5.7 years and only two patients have actually reached 10 years. No confidence intervals are provided, but we may assume that these are large.
More important, however, is what happens to the autograft and left ventricle after the operation and whether these observations are relevant for the long term. Two of 12 survivors have a limited residual valve gradient. Seven of the 12 patients have aortic regurgitation; one patient required reoperation for moderate regurgitation, and trivial regurgitation progressed to mild in 6 patients. These data portend a steady increase in aortic regurgitation that will eventually require reoperation, as already reported by others. In this series, the pulmonary autograft annular diameter increased from 17.3 ± 4.1 to 22.4 ± 6.3 mm, but no dilatation occurred at the annular or sinotubular junction beyond somatic growth. No information is provided on the pattern of dilatation (eg, whether part of this increase in diameter occurred early after implantation). In addition, 4 patients developed pulmonary regurgitation, which required reoperation in 3. Two patients had a gradient across the right ventricular outflow tract. The report does not provide data on left ventricular function.
This small series confirms that the Ross-Konno procedure, like the Ross procedure, is effective in relieving the left ventricular outflow tract obstruction, but may replace the original stenosis with aortic regurgitation in time. The number of patients is too small and the follow-up is too short to claim excellent results. However, since there are hardly any alternatives, the present outcomes are certainly adequate and Brown and colleagues [1] should be commended for their contribution. Nevertheless, regurgitation and autograft dilatation are increasingly observed; therefore, these patients should be closely monitored indefinitely.
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