Murin P, Weixler VHM, Moulla-Zeghouane J, Romanchenko O, Schleiger A, Lorenzen V, Sinzobahamvya N, Zacek P, Photiadis J, Cho MY.Eur J Cardiothorac Surg. 2021 Jan 4;59(1):226-233. doi: 10.1093/ejcts/ezaa307.PMID: 33141218
Take Home Points:
- Subcoronary Ross/Ross-Konno operation is a choice for children who are not indicated for graft-enforced Ross procedure.
- Size mismatch between aortic and pulmonary annulus is not a problem as the aortic annulus and LVOT can be enlarged with Konno incision +/- additional patch in the non-coronary sinus.
Commentary from Dr. Yasuhiro Kotani (Okayama, Japan), section editor of Congenital Heart Surgery Journal Watch:
Summary:
A total of 50 patients with median age of 6.3 years who underwent subcoronary Ross/Ross-Konno operation was reviewed. After the harvest, the autograft was trimmed just to leave some tissues for the implantation. The annulus was enlarged when necessary. Konno incision was performed in 42 (84%) patients, including 24 patients with LVOTO and/or annular hypoplasia and 18 patients with a size mismatch between aortic and pulmonary annulus. An additional patch for non-coronary sinus was used in 17 (34%) patients. The autograft rotation was decided based on the orientation of the coronary artery ostium. Overall survival was 95%. Freedom from aortic valve regurgitation more than mild was 97% at 5years and only 2 (4%) patients required aortic valve replacement. No aortic root dilation was seen in the mid-term follow-up.
Significance:
Aortic valve surgery in children and young adults has several options, such as Ross procedure and aortic valve replacement with or without Konno, however, it is still in debate what procedure to be selected as the reconstructed aortic valve and the root should be grown. Subcoronary Ross/Ross-Konno procedure may be the answer that overcomes the disadvantages of aortic valve replacement and Ross procedure.
Comment:
No standard care was shown in the surgical treatment of the aortic valve in children and young adults. These patients are at age of somatic growth and this makes the choice of surgery difficult. Aortic valve replacement with or without Konno promises a longevity unless adverse events related to the prosthetic valve happen. Patients who are athletes and female may not be suitable as it requires warfarin in lifetime. In contrast, Ross procedure has a benefit for a potential growth of the autograft and no need for anticoagulation, however it creates 2-valve diseases and the dilatation of the implanted autograft remains an issue, especially for patients with a bicuspid valve. As originally described by Dr. Ross in 1967, subcoronary Ross should be taken into reconsideration. There are certainly some technical tips but it might be theoretically better option for children and young adults for potential growth without root dilatation. Size mismatch between aortic and pulmonary root can be always addressed by additional Konno-incision and patch for non-coronary sinus and fits for small children before school age.
