Comprehensive surgical technique for the neonatal and infant Ross Konno procedure – technical pearls
Affiliations & Notes
Sydney Children's Hospitals Network, Heart Centre for Children, Department of Cardiothoracic Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
Article Info
Publication History:
Received April 22, 2024; Accepted July 25, 2024; Published online October 16, 2024
Footnotes:
Disclosure statement: the authors have no disclosures, no conflicts of interest and did not receive any funding for this study.
DOI: 10.1053/j.optechstcvs.2024.07.006 External LinkAlso available on ScienceDirect External Link
Copyright: Crown Copyright © 2024 Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Linked Articles (0)
Keywords
Get full text access
Log in, subscribe or purchase for full access.
References
1.
Christensen, AH ∙ Chaturvedi, RR ∙ Callahan, CP ...
Current-era outcomes of balloon aortic valvotomy in neonates and infants
JACC Adv. 2022; 1(1), 100004
2.
Olofsson, CK ∙ Hanseus, K ∙ Ramgren, JJ ...
Outcomes in neonatal critical and non-critical aortic stenosis: a retrospective cohort study
Arch Dis Child. 2023; 108(5):398-404
3.
Siddiqui, J ∙ Brizard, CP ∙ Galati, JC ...
Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization
J Am Coll Cardiol. 2013; 62(22):2134-2140
4.
Shinkawa, T ∙ Bove, EL ∙ Hirsch, JC ...
Intermediate-term re- sults of the Ross procedure in neonates and infants
Ann Thorac Surg. 2010; 89:1827-1832
5.
Mookhoek, A ∙ Charitos, EI ∙ Hazekamp, MG ...
Ross procedure in neonates and infants: a European multicenter experience
Ann Thorac Surg. 2015; 100:2278-2284
6.
Elder, RW ∙ Quaegebeur, JM ∙ Bacha, EA ...
Out- comes of the infant Ross procedure for congenital aortic stenosis followed into adolescence
J Thorac Cardiovasc Surg. 2013; 145:1504-1511
7.
Luciani, GB ∙ Lucchese, G ∙ Carotti, A ...
Two decades of experience with the Ross operation in neonates, infants and children from the Italian Paediatric Ross registry
Heart. 2014; 100:1954-1959
8.
Sames-Dolzer, E ∙ Wickenhauser, E ∙ Kreuzer, M ...
The Ross-Konno procedure in neonates and infants less than 3 months of age
Eur J Cardiothorac Surg. 2018; 54:71-77
9.
Nelson, JS ∙ Pasquali, SK ∙ Pratt, CN ...
Long-term survival and reintervention after the Ross procedure across the pediatric age spec- trum
Ann Thorac Surg. 2015; 99:2086-2094
10.
Lo Rito, M ∙ Davies, B ∙ Brawn, WJ ...
Comparison of the Ross/Ross-Konno aortic root in children before and after the age of 18 months
Eur J Cardiothorac Surg. 2014; 46:450-457
11.
Rowe, G ∙ Gill, G ∙ Mujeeb Zubair, MM ...
Ross Procedure in Children: The Society of Thoracic Surgeons Congenital Heart Surgery Database Analysis
Ann Thorac Surg. 2023; 115(1):119-125
12.
Winlaw DS, Greenberg JW, O'Donnell AP. The Ross and Ross-Konno operation in neonates and infants. operative techniques in thoracic and cardiovascular surgery 2022; 27: 423-446.doi: 10.1053/j.optechstcvs.2022.07.00313.
Luxford, JC ∙ Ayer, JG ∙ Betts, K ...
The Ross/Ross-Konno procedure in infancy is a safe and durable solution for aortic stenosis
J Thorac Cardiovasc Surg. 2022; 163:365-375
14.
Geens, M ∙ Gonzalez-Lavin, L ∙ Dawbarn, C ...
The surgical anatomy of the pulmonary artery root in relation to the pulmonary valve autograft and surgery of the right ventricular outflow tract
J Thorac Cardiovasc Surg. 1971; 62(2):262-267
15.
Starnes, VA ∙ Bowdish, ME ∙ Cohen, RG ...
The Ross procedure utilizing the pulmonary autograft inclusion technique in adults
JTCVS Tech. 2021; 10:372-376
Figures (15)
Article metrics
-
2Captures
Figure 1 Optimal lines of incision to enable proximal and distal mobilization of the pulmonary autograft and the line of transection of the often hypoplastic ascending aorta at the sinotubular junction.
Figure 2 The site of transection of the distal main pulmonary artery relative to the sinotubular junction (STJ) of the main pulmonary artery in order to preserve the STJ and proximal main pulmonary artery distal to the STJ for placement of the autograft outflow suture line.
Figure 3 Mobilisation of the pulmonary root by low voltage electrocautery dissection taking care to preserve the left main coronary artery and it's branches as it passes posterior to the pulmonary root.
Figure 4 Cross-sectional diagrams demonstrating the relationship of pulmonary autograft to the aortic root and coronary arteries and preservation of the subpulmonary conal muscle at various points around the pulmonary valve annulus (a-a: posterior infundibular free wall, b-b: anterior RV free wall, c-c interventricular septum demonstrating hinge points of both the aortic and pulmonary valve leaflets).
Figure 5 Identification of the appropriate site on the anterior wall of the infundibulum to commence the proximal harvest of the pulmonary autograft using a right angle passed across the pulmonary valve to locate a safe region several millimetres below the nadir of the pulmonary valve cusp in the left anterior sinus.
Figure 6 Anatomy of the interventricular septum in the region of the subpulmonary infundibulum and its relationship to the left main, left anterior descending and septal perforating coronary arteries.
Figure 7 Mobilisation of the coronary artery buttons after harvesting of the pulmonary autograft and placing it within the pericardial space for later use.
Figure 8 Orientation of the Konno incision in the interventricular septum with the tip of the scissors pointing towards the left ventricular apex.
Figure 9 Cross sectional illustration of the orientation for the Konno incision through the interventricular septum relative to surrounding anatomic structures including the left ventricular apex and the epicardial course of the coronary arteries.
Figure 10 Surgeon's view of set up of the left ventricular (LV) outflow for implantation of the pulmonary autograft at the inflow suture line. Commissural stay sutures have been placed to facilitate suture spacing and alignment around the LV outflow tract (LVOT). Anatomic relations of the LVOT including the mitral valve, interventricular septum and coronary arteries are also illustrated. Numbers in the Figure describe suture spacing around the LVOT and autograft as per the operative description.
Figure 11 Placement of suture bites to approximate the pulmonary autograft muscle to the LVOT illustrating spacing around circumference required to accommodate the LVOT components around the autograft inflow suture line (A) Cross sectional anatomy, (B) longitudinal view. Numbers provide the same reference as in Figure 10.
Figure 12 Implantation of the coronary buttons into their respective sinuses once the proximal inflow suture line of the autograft in the the LV outflow tract has been completed.
Figure 13 Construction of the outflow sutureline between the larger autograft sinotubular junction and the smaller native preserved aortic sinotubular junction demonstrating sutureline orientation and creation of a longitudinal relieving incision to accommodate the larger autograft circumference into the smaller ascending aorta.
Figure 14 Upper diagram demonstrates cross sectional anatomy of the RVOT in the autograft bed and location of the LAD and septal perforator indicating strategy for suture placement to implant the RV to pulmonary artery (PA) conduit (homograft). Lower diagram is a cross sectional representation of the RVOT and surrounding structures demonstrating the optimal orientation of an aortic homograft being used for construction of RV to PA continuity.
Figure 15 Careful placement of superficial suture bites on the posterior aspect of the RVOT in the autograft bed is essential to avoid the LAD and septal perforator artery as emphasized in the inset diagram.
