Ross operation

The Ross operation, introduced by Donald Ross in 1967,Reference Ross¹⁷ has many advantages that include autologous pulmonary autograft aortic valve replacement, the potential for autograft growth, and freedom from lifelong anticoagulation therapy.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis^14, Reference Stewart, Backer, Hillman, Lundt and Mavroudis¹⁸ The disadvantages include an almost certain future operative or transcatheter neopulmonary artery homograft replacement and the possibility of neoaortic dilatation, which can lead to valve failure. The possibility of transforming a patient with single-valve disease to double-valve disease is a rare but ominous possibility. The accrued long-term experience with this operation, however, has been favourableReference Brown, Ruzmetov, Vijay, Bills and Turrentine¹⁹ and it has become the valve-replacement strategy of choice for infants, children, and young adults, when simple commissurotomy cannot be accomplished or when valve leaflet extensions options are not elected or not preferred.Reference Cox, Walton, Bartz, Tweddell, Frommelt and Earing^20–Reference Tweddell, Pelech and Jaquiss²³

Figure 1 shows an operative drawing that features a patient with aortic valve disease who is being prepared for a Ross procedure.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ Aortobicaval cardiopulmonary bypass with left ventricular venting (not depicted), antegrade and retrograde (catheter is noted) hypothermic cardioplegia, aortic transection, and the beginning of the pulmonary autograft harvest are shown. Figure 2 shows the same drawing in colour and without the highlighted notes so as to introduce the subsequent colour drawings. The aortic valve resection, coronary artery button dissection, distal pulmonary autograft transection, and proximal pulmonary autograft harvesting from the right ventricular outflow tract are depicted in Figure 3. There are several relevant points that can be made concerning these procedural manoeuvres. The degree of aortic valve resection is dependent on the actual size of the aortic annulus. Assuming that the operation is being performed for aortic stenosis, and if the annulus size is small, then the aortic leaflet resection can be more extensive and may include a portion of the annulus away from the conduction system, the mitral valve, and right coronary artery. Interruption of the aortic valve annulus permits the remaining annulus to “stretch” and permit a better alignment for the pulmonary autograft, which should be only 1–3 mm larger than the remaining aortic annulus for a favourable outcome. In the situation that the operation is performed for aortic insufficiency, and if the aortic annulus is large, a reduction annuloplasty will be necessary by placating the annulus with pledgeted supportive sutures so that the pulmonary autograft fits snuggly into the resultant downsized annulus to prevent neoaortic regurgitation. The distal pulmonary autograft is transected close to the commissures to ensure that the minimum amount of the pulmonary artery wall is subject to systemic pressures. This anatomic configuration assures the smallest potential for distention and distortion, which can lead to unwanted aortic regurgitation. The proximal pulmonary autograft harvest is performed with precision to avoid injury to the left anterior descending coronary artery and the first septal perforating branch, which is very close to the pulmonary artery conus. Gentle probing of the left main coronary artery with sized dilators will depict the anatomic course of the coronary arteries. Conscientious attention to detail and accurate dissection will result in preserving enough conus for the proximal aortic annulus anastomosis while preserving the integrity of the coronary arteries. After the pulmonary autograft is harvested, retrograde cardioplegia can be instituted to expose and observe any potential bleeding sites from the interventricular septum wherefrom the autograft was harvested. This can be performed by a combination of superficial suture ligation and electrocautery coagulation. Attentive haemostasis during this stage of the operation when the exposure is optimal will prevent bleeding at the end of the operation when exposure is challenging and difficult.

Figure 1

Aortic transection and initiation of pulmonary autograft harvest. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 2

Colour representation of Figure 1 without the annotations.

Figure 3

Later stages of autograft harvest and coronary artery button mobilisation.

Figure 4 illustrates the initial stages of the autograft implantation into the left ventricular outflow tract after reduction annuloplasty was performed for an optimal alignment between the aortic annulus and the proximal pulmonary autograft. The proximal pulmonary autograft should be approximately 2–4 mm larger than the aortic annulus to prevent proximal neoaortic dilatation.

Figure 4

Aortic annulus reduction (pledgeted sutures) and the initiation of the autograft implantation.

One of the sinuses of valsalva is aligned with the left main coronary artery button before the running suture line is initiated. The first suture line is accomplished to accurately implant the autograft and a second suture line is placed for haemostasis. The second suture line is placed strategically between the previous suture line in the anastomotic areas that are likely to cause bleeding. The sutures are also placed more superficially to avoid valve leaflet injury. We have found this double suture technique to be very effective in preventing suture line bleeding.

Figure 5 shows the completed double suture line, attachment of the left main coronary button, and the right coronary button anastomosis in progress. Not enough can be written about careful attention to accurate suture placement to ensure haemostasis and suppress unwanted bleeding at the end of the operation, especially in locations that are difficult to expose. Retraction to expose, visualise, and control a bleeding point may disrupt the reconstruction and threaten the patient’s well-being. In keeping with this theme, the right ventricular outflow tract reconstruction also demands haemostasis precautions. Before removal of the cross-clamp, the surgeon should consider performing and completing the proximal pulmonary homograft anastomosis to avoid injury to the left anterior descending coronary artery and the neoaortic reconstruction. A motionless heart in a bloodless field will optimise accuracy and prevent persistent bleeding.

Figure 5

Coronary button attachment to the autograft to form the neoaorta.

Figure 6 shows the completed neoaortic reconstruction after the air manoeuvres have been performed and the cross-clamp removed. Some surgeons have used a circular piece of Teflon felt to fix the annular anastomosis in patients who have attained physiological maturity and reached ultimate somatic growth.Reference Brown, Ruzmetov, Vijay, Bills and Turrentine¹⁹ Others, in similar circumstances, have used a sinus of the valsalva graft to support the pulmonary homograft, thereby preventing autograft dilatation.Reference Slater, Shen, Welke, Komanapalli and Ungerleider²⁴ This is accomplished by first situating and suturing the autograft inside of the sinus of valsalva graft and then implanting the composite graft into the left ventricular outflow tract. The reconstruction is completed by anastomosing the coronary buttons to the graft. Clearly, these manoeuvres are reserved for patients who have achieved somatic growth and not for the growing infant, child, and young adolescent. The neopulmonary reconstruction is shown to be completed while the patient is being rewarmed in anticipation of separation from cardiopulmonary bypass. Figure 7 shows the completed Ross operation after catheter removal. Transoesophageal echocardiography attests to the integrity of the repair and documents the findings for future comparisons.

Figure 6

Completed neoaortic reconstruction, cross-clamp removal, and neopulmonary artery reconstruction in progress.

Figure 7

Completed Ross operation.

Konno–Rastan operation

The classic Konno–Rastan operation,Reference Konno, Imai, Iida, Nakajima and Tatsuno^15, Reference Rastan and Koncz²⁵ or more simply the Konno operation, is rarely applied in the current era yielding to less deforming operations such as the Ross–Konno operation, which requires less of an incision into the interventricular septum.Reference Mavroudis and Backer²⁶ Nevertheless, when the aortic annulus is very small, surgeons may opt to apply this operation. Figure 8 illustrates the operative exposure and preliminary conditions that are implemented for the Konno operation.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ Aortobicaval cardiopulmonary bypass with aortic cross-clamping is shown with the anticipated incisions (dotted line) on the aorta and right ventricle. The left ventricular vent and antegrade and retrograde cardioplegia administration apparatus that are foundational for this type of operation are not depicted. The aortic incision is commenced above the aortic commissures and extended to the annulus keeping the right coronary artery orifice to the right of the incision referenced to the surgeon and keeping the left coronary artery orifice to the left. The incision is carried onto and through the right ventricular outflow tract with special attention not to injure the proximal portion of the pulmonary artery conus and pulmonary leaflets that are very close to this incision. At this point, the two cardiac chambers, the aorta and the right ventricle, are exposed. An incision can then be made across the aortic annulus, respecting the course of the conduction system into the interventricular septum (Fig 9).Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ It can be anticipated that the septum will be very thick owing to the established concentric left ventricular hypertrophy. This incision in the interventricular septum is extended into the left ventricular outflow tract for enough length, approximately 2–3 cm, to ensure a proper outflow size. The mechanical or bioprosthetic stented valve can now be placed in the left ventricular outflow tract. Pledgeted sutures are placed into the posterior aortic annulus and through the prosthetic valve sewing ring for ∼40 to 50% of the anticipated new annulus. A synthetic patch is then configured and measured to ensure valve implantation, augmentation of the subvalvar outflow tract at the level of the incised interventricular septum, and to the ascending aorta. The proximal patch is anchored to the edges of the incised interventricular septum by interrupted pledgeted sutures to avoid patch disruption and residual ventricular septal defect. This effectively and optimally enlarges the left ventricular outflow tract. The anterior sewing ring of the prosthetic valve is then attached to the patch material using interrupted suture technique, as noted in Figure 10.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ The same patch is then aligned with the edges of the ascending aorta and used to augment the ascending aorta, as depicted in Figure 10.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ The remainder of the operation is performed to augment the right ventricular outflow tract using a piece of a redundant pericardial patch. Care is exercised to avoid stenosis and prevent regurgitation of the pulmonary valve. The pericardial patch is sewn to the right ventricular incised wall, and the superior portion is attached to the aortic portion of the graft (Fig 11).Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ Most surgeons prefer to use a mechanical valve for this operation as a very large valve size can be implanted. Hypothetically, this operation was conceived and applied with the thought that it would be the last and curative procedure for the patient. Long-term complications involving pannus ingrowth, somatic development, thromboembolism, complete heart block requiring pacemakers, warfarin management, and endocarditis occur in enough patients to challenge this theoretical claim.

Figure 8

Operative conditions and proposed incisions (dashed lines) in preparation for the Konno operation. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 9

Incisions made into the aorta, the right ventricle, and the interventricular septum for left ventricular outflow tract enlargement. Interrupted sutures are started for the mechanical valve implant. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 10

Aortoseptoplasty is in progress to open the left ventricular outflow tract, implants the mechanical valve, and enlarges the ascending aorta. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 11

The Konno operation is shown completed with the right ventricular outflow tract reconstruction using a pericardial patch. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Modified Konno operation

The modified Konno operation was developed to optimise left ventricular outflow tract relief while preserving native aortic valve function when transaortic subvalvar resection is not feasible.Reference Mavroudis, Backer and Kaushal²⁷ The operative approach and exposure is established by aortobicaval cardiopulmonary bypass, aortic cross-clamping, left ventricular venting, and antegrade/retrograde cardioplegic arrest, as shown in Figure 12.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ Initially, the aorta and right ventricle are incised to expose the right ventricular outflow tract and the transeptal left ventricular outflow tract. The subaortic area can be inspected through the aortic valve and a clamp can be introduced to delineate a safe site in the interventricular septum below the aortic valve annulus where the initial incision can be made. The interventricular septum is then incised away from the conduction system and extended into the left ventricular cavity. Careful fibromuscular excision is then performed to resect the causative obstructive muscles and fibromuscular bundles, as noted in Figure 13.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ The superior extent of the resection requires accurate identification of the aortic annulus and valve to avoid valve injury, which, if it occurs, will defeat the purpose of the operation, which is to preserve valve function while resecting the offending subvalvar muscle bundles. This can be achieved with a suture placement through the aorta and into the aortic annulus, which can be identified from the interventricular septal incision. The subvalvar fibrous stenosis can oftentimes be indistinguishable from the valve tissue owing to the fibrous nature of the stenosis and the thickened aortic leaflets. Nevertheless, extreme care and deliberate staged incisions/excisions will result in the anticipated outcome, assuming that the aortic annulus is reasonably sized and the left ventricular function is preserved.

Figure 12

Operative conditions and proposed incisions (dashed lines) in preparation for the modified Konno operation. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 13

Right ventriculotomy, aortotomy, and interventricular septal incision/excision for subaortic valvar outflow tract augmentation. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

A patch can then be placed within the right ventricle to augment the left ventricular outflow tract, as shown in Figure 14.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹ The aorta and right ventricle can then be closed; the air manoeuvres can be accomplished; and the cross-clamp can be removed. The completed operation is illustrated in Figure 15.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹

Figure 14

The incised interventricular septum is augmented by a synthetic patch. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 15

The completed modified Konno operation showing the cavitary suture line closures. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Ross–Konno operation

The Ross–Konno operation takes advantage of two important surgical principles that combine to relieve left ventricular outflow tract obstruction, provide for a competent autograft, offer growth potential, and establish freedom from anticoagulation regimens. Figure 16 shows the incisions for aortic transection and autograft harvesting.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis^1, Reference Reddy, Rajasinghe, Teitel, Haas and Hanley^9, Reference Clarke^28, Reference Sardari, Gundry, Razzouk, Shirali and Bailey²⁹ The tenets that guide these techniques are reviewed in the previous section on the Ross operation. Figure 17 illustrates the procedural steps that have resulted in pulmonary autograft harvest, aortic valve resection, and coronary button preparation.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis^1, Reference Reddy, Rajasinghe, Teitel, Haas and Hanley^9, Reference Clarke^28, Reference Sardari, Gundry, Razzouk, Shirali and Bailey²⁹ Importantly, this drawing shows that the incision in the interventricular septum is carried out for only a short distance without right ventricular outflow tract distortion and limiting the potential for injury to the conduction system. This incision together with segmental aortic annulus resection will expand the annular area for enough distance to accept implantation of the pulmonary autograft without residual obstruction. This limited incision into the interventricular septum is associated with a lower incidence of complete heart block than what has been shown for the Konno operation. The pulmonary autograft is then implanted with a double layer of running suture technique and coronary artery implantation as noted in the section on the Ross operation. Figure 18 illustrates the completed neoaortic reconstruction before implementing the air manoeuvres and removal of the aortic cross-clamp.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis^1, Reference Reddy, Rajasinghe, Teitel, Haas and Hanley^9, Reference Clarke^28, Reference Sardari, Gundry, Razzouk, Shirali and Bailey²⁹ The left anterior descending coronary artery course and the left atrial appendage are identified and respected. An oversized pulmonary homograft, when available, is then implanted into the right ventricular outflow tract to complete the operation, as noted in Figures 19.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis^1, Reference Reddy, Rajasinghe, Teitel, Haas and Hanley^9, Reference Clarke^28, Reference Sardari, Gundry, Razzouk, Shirali and Bailey²⁹ Recent advances in conduit technology have permitted surgeons to use alternative material to construct right ventricular to pulmonary artery continuity. Time will tell which conduits have the greater long-term function and longevity.

Figure 16

The lines of incision are shown (dashed lines) for aortic transection and autograft harvest en route to a Ross–Konno operation. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 17

The harvested autograft, coronary button mobilisation, and limited interventricular septal incision are shown in preparation for the autograft implantation. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 18

The neoaortic reconstruction just before removal of the aortic cross-clamp and in anticipation of the neopulmonary artery reconstruction. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

Figure 19

Completed Ross–Konno operation with reconstruction of the neoaorta and the neopulmonary artery. (Reproduced with permission from Tchervenkov et al. Left ventricular outflow tract obstruction. In Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 4th ed. Copyright © 2013 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.Reference Tchervenkov, Bernier, Del Duca, Hill, Ota and Mavroudis¹).

During the developmental stages leading to the Ross–Konno operation, some surgeons endeavoured to use autologous material to augment the left ventricular outflow tract in an effort to limit the use of synthetic material. This would theoretically insert the growing tissue into the interventricular septum and eliminate the chance of recurrent left ventricular outflow tract obstruction.

Figure 20 shows the aforementioned incisions that are used for the Ross operation, with the exception that an extension or “apron” of the right ventricular free wall is included in the pulmonary autograft harvest.Reference Mavroudis, Backer and Kaushal²⁷ This connected and autologous tissue was thought to have the potential to augment the left ventricular outflow tract. Figure 21 illustrates the harvested autograft with the attached “apron” of the right ventricular free wall.Reference Mavroudis, Backer and Kaushal²⁷ The proposed incision (dotted line) in the interventricular septum is also shown. Note that the proposed incision in the interventricular septum approximates the length of the larger incision that is performed for the Konno operation. Also shown in Figure 21 are the dissected coronary buttons and resected aortic valve from the aortic annulus.Reference Mavroudis, Backer and Kaushal²⁷ After the incision in the interventricular septum is made, the autograft is aligned to the left ventricular outflow tract in such a manner as to situate the “apron” into the incised septum and implant the rest of the autograft into the annulus. The completion of the coronary button anastomoses and the distal aortic connection are shown before removal of the cross-clamp in Figure 22.Reference Mavroudis, Backer and Kaushal²⁷

Figure 20

Proposed incisions (dashed lines) for aortic transection, coronary button dissection, and pulmonary autograft harvest with an “apron” of the right ventricular free wall and will function as the left ventricular outflow tract augmentation patch. (Reproduced with permission from Mavroudis et al. Aortic stenosis and aortic insufficiency in children: impact of valvuloplasty and modified Ross-Konno procedure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009;12:76-86. Copyright © 2009, with permission from ElsevierReference Mavroudis, Backer and Kaushal²⁷).

Figure 21

Interventricular septal incision (dashed line), pulmonary autograft harvest, and autograft coronary implantation sites (circular dashed lines) in preparation for pulmonary autograft placement and left ventricular outflow tract augmentation. (Reproduced with permission from Mavroudis et al. Aortic stenosis and aortic insufficiency in children: impact of valvuloplasty and modified Ross-Konno procedure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009;12:76-86. Copyright © 2009, with permission from ElsevierReference Mavroudis, Backer and Kaushal²⁷).

Figure 22

Neoaortic reconstruction using the “apron” right ventricular free wall extension for left ventricular outflow tract augmentation just before release of the aortic cross-clamp. (Reproduced with permission from Mavroudis et al. Aortic stenosis and aortic insufficiency in children: impact of valvuloplasty and modified Ross-Konno procedure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009;12:76-86. Copyright © 2009, with permission from ElsevierReference Mavroudis, Backer and Kaushal²⁷).

Figure 23 shows the completed reconstruction after the completed pulmonary homograft implantation and separation from cardiopulmonary bypass.Reference Mavroudis, Backer and Kaushal²⁷ While ingenious and attractive in both concept and application, this interventricular “apron” patch proved to be fraught with complications leading to residual ventricular septal defect, false aneurysms, and pulmonary stenosis in some patients relegating this application to an “alternative approach” to be used only in specialised situations or for that matter, not at all.

Figure 23

Completed Ross–Konno operation using the right ventricular free wall extension as the “apron” and the right ventricular to pulmonary artery homograft to construct the neopulmonary artery. (Reproduced with permission from Mavroudis et al. Aortic stenosis and aortic insufficiency in children: impact of valvuloplasty and modified Ross-Konno procedure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009;12:76-86. Copyright © 2009, with permission from ElsevierReference Mavroudis, Backer and Kaushal²⁷).

Modified Ross–Konno operation

The modified Ross–Konno operation was introduced in 2005 to place the left ventricular outflow tract augmentation incision away from the interventricular septum and therefore away from the conduction system.Reference Mavroudis and Backer²⁶ The initial and preparatory steps of the modified Ross–Konno operation are the same as the Ross–Konno operation. The pulmonary autograft, as shown in Figure 24, is harvested with the same precautions and safeguards.Reference Mavroudis and Backer²⁶ Ordinarily, we would use the aortic cross-clamp for the autograft harvest. In this drawing, the harvest is being performed in a beating, non-working heart, which is an alternative and acceptable procedure. After appropriate cardioplegic arrest, the aorta is cross-clamped and transected. The coronary buttons are dissected and mobilised, as depicted in Figure 25.Reference Mavroudis and Backer²⁶ The dotted line, adjacent to the left main coronary button, is the area of the anticipated incision to effect enlargement of the left ventricular outflow tract. Figure 26 illustrates the extensive debridement of the aortic annulus and incision of the left ventricular outflow tract posterior to the course of the left main coronary button.Reference Mavroudis and Backer²⁶ Care is taken to dissect and mobilise this coronary button much the same way as for an arterial switch operation using a combination of blunt and sharp dissection. When used, the electrocautery settings should be very low so that the incision does not injure the artery. The dissection should be extensive enough so that pledgeted sutures can be placed during the neoaortic reconstruction. Figure 27 shows the pledgeted sutures situated circumferentially around the left ventricular outflow tract.Reference Mavroudis and Backer²⁶ These reinforced sutures are mandatory to optimise autograft anchoring to the unsupported muscular collar of the left ventricular outflow tract. Without these pledgets, the autograft can become dislodged leading to significant complications. The valve is then implanted into the left ventricular outflow tract and the sutures are tied securely. Figure 28 illustrates the implanted autograft, the completed left coronary artery button anastomosis, and the right coronary artery button anastomosis in progress.Reference Mavroudis and Backer²⁶ The neoaorta and the ascending aorta are connected to complete the neoaortic reconstruction, as noted in Figure 29.Reference Mavroudis and Backer²⁶ The completed cardiac reconstruction is illustrated in Figure 30.Reference Mavroudis and Backer²⁶ The potential disadvantages of this operation centre on the proximity of the autograft implantation site to the left main coronary artery and the potential possibility that the pledgeted suture placement into the myocardium can disrupt. These sutures must be placed carefully to insure proper autograft implantation to ensure optimal utility and haemostasis.

Figure 24

Pulmonary autograft in progress (dashed lines) in preparation for the modified Ross–Konno operation. (Reproduced with permission from Mavroudis et al. Technical tips for three congenital heart operations: Modified Ross-Konno procedure, optimal ventricular septal defect exposure by tricuspid valve incision, coronary unroofing and endarterectomy for anomalous aortic origin of the coronary artery. Oper Tech Thorac Cardiovasc Surg 2010;15:18-40. Copyright © 2010, with permission from ElsevierReference Mavroudis and Backer²⁶).

Figure 25

Harvested pulmonary autograft, mobilised coronary artery buttons, and proposed incision into the left ventricular free wall (dashed line) for left ventricular outflow tract enlargement. (Reproduced with permission from Mavroudis et al. Technical tips for three congenital heart operations: Modified Ross-Konno procedure, optimal ventricular septal defect exposure by tricuspid valve incision, coronary unroofing and endarterectomy for anomalous aortic origin of the coronary artery. Oper Tech Thorac Cardiovasc Surg 2010;15:18-40. Copyright © 2010, with permission from ElsevierReference Mavroudis and Backer²⁶).

Figure 26

Aortic annulus resection and enlarging incision in the left free wall in preparation for left ventricular augmentation for the modified Ross–Konno operation. (Reproduced with permission from Mavroudis et al. Technical tips for three congenital heart operations: Modified Ross-Konno procedure, optimal ventricular septal defect exposure by tricuspid valve incision, coronary unroofing and endarterectomy for anomalous aortic origin of the coronary artery. Oper Tech Thorac Cardiovasc Surg 2010;15:18-40. Copyright © 2010, with permission from ElsevierReference Mavroudis and Backer²⁶).

Figure 27

Pulmonary artery autograft shown being implanted into the enlarged left ventricular outflow tract using mattress pledgeted sutures to insure stability and haemostasis. (Reproduced with permission from Mavroudis et al. Technical tips for three congenital heart operations: Modified Ross-Konno procedure, optimal ventricular septal defect exposure by tricuspid valve incision, coronary unroofing and endarterectomy for anomalous aortic origin of the coronary artery. Oper Tech Thorac Cardiovasc Surg 2010;15:18-40. Copyright © 2010, with permission from ElsevierReference Mavroudis and Backer²⁶).

Figure 28

Coronary artery reimplantation into the pulmonary autograft en route to neoaortic reconstruction. (Reproduced with permission from Mavroudis et al. Technical tips for three congenital heart operations: Modified Ross-Konno procedure, optimal ventricular septal defect exposure by tricuspid valve incision, coronary unroofing and endarterectomy for anomalous aortic origin of the coronary artery. Oper Tech Thorac Cardiovasc Surg 2010;15:18-40. Copyright © 2010, with permission from ElsevierReference Mavroudis and Backer²⁶).

Figure 29

Ascending aorta to neoaorta end-to-end anastomosis. (Reproduced with permission from Mavroudis et al. Technical tips for three congenital heart operations: Modified Ross-Konno procedure, optimal ventricular septal defect exposure by tricuspid valve incision, coronary unroofing and endarterectomy for anomalous aortic origin of the coronary artery. Oper Tech Thorac Cardiovasc Surg 2010;15:18-40. Copyright © 2010, with permission from ElsevierReference Mavroudis and Backer²⁶).

Figure 30

Completed modified Ross–Konno operation showing neoaortic and neopulmonary artery reconstructions. (Reproduced with permission from Mavroudis et al. Technical tips for three congenital heart operations: Modified Ross-Konno procedure, optimal ventricular septal defect exposure by tricuspid valve incision, coronary unroofing and endarterectomy for anomalous aortic origin of the coronary artery. Oper Tech Thorac Cardiovasc Surg 2010;15:18-40. Copyright © 2010, with permission from ElsevierReference Mavroudis and Backer²⁶).

Comment

Methods to optimise the relief of left ventricular outflow tract obstruction and to ensure proper aortic valve function have improved over the years. Advances in myocardial protection promulgated by newer cardioplegic solutions have afforded surgeons the cardioplegic arrest time to attempt more complex operations that will allow accurate repairs.Reference Matte and del Nido³⁰ No doubt further improvements will be in the horizon and may make aortic valve leaflet extension a more durable operation. Right ventricular to pulmonary artery conduit problems may be cured by the autologous stem cells and tissue engineering. In the meantime, however, significant left ventricular outflow tract obstruction requires careful operative planning and conscientious operative execution, as noted in this review article, to avoid the pitfalls of heart block, perioperative bleeding, left ventricular dysfunction, and right ventricular outflow tract problems.