The Ross-Konno Procedure in Children: Subcoronary Inclusion Technique with Konno Incision for Annular and Subannular Hypoplasia

Objectives: The subcoronary inclusion technique for autograft aortic valve replacement has shown excellent durability of the aortic valve function with preserved aortic annular dimensions. However, the use in hypoplastic aortic annulus or multilevel left ventricular obstruction was traditionally precluded. Our strategy combines the enlargement of the left ventricular outflow tract by Konno incision with the advantages of the subcoronary inclusion into the preserved aortic annulus.

Methods: A 2-year-old boy with severe aortic valve stenosis and regurgitation after balloon angioplasty of a unicuspid aortic valve with hypoplastic aortic annulus, underwent Ross-Konno procedure using a modified subcoronary inclusion technique for the reimplantation of the autograft. Bicaval cannulation and full flow bypass with mild hypothermia were used.

The aorta was cross-clamped and opened deep into the non-coronary sinus. Cardioplegia delivery was directly into the coronary ostia. The aortic valve was not suitable for reconstruction and was completely excised. The pulmonary autograft was harvested, and the diameter was 5 mm larger than the size of the aortic annulus. The Konno incision of the interventricular septum was performed to accommodate for the size discrepancy. The incision was enlarged using an autologous pericardial patch. The autograft was inverted and reimplanted in subcoronary fashion retaining optimal geometry and additional external support by the native aortic annulus.

Results: The patient was extubated on the same operative day and discharged home on 6th postoperative day without residuals. The left ventricular outflow tract was free of obstruction, and the autograft aortic valve was competent.

Conclusion: The Ross-Konno procedure using the subcoronary inclusion technique in combination with enlargement of the aortic annulus and left ventricular outflow tract is feasible even in patients with severe discrepancy between the autograft and native aortic annular diameters.