The Ross/Konno Procedure Peter Pastuszko, Thomas L. Spray  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 7, Issue 4, Pages 195-206 (November 2002) DOI: 10.1053/otct.2002.36324 Copyright © 2002 Elsevier Inc. Terms and Conditions

1 After a standard median sternotomy is performed, the aorta is cannulated distally, close to the origin of the innominate artery. This facilitates the exposure and subsequent dissection. The superior and inferior vena cavae are cannulated separately. The aorta and the pulmonary artery are extensively mobilized, and the adventitial plane between the two vessels is dissected proximally, close to the origin of the right coronary artery. The aortic arch is examined for any abnormalities and landmarks are identified for subsequent incisions. Cardiopulmonary bypass is initiated and the patient is cooled. A left ventricular vent is placed through the right superior pulmonary vein. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

2 The aorta is cross-clamped and cardiopegia administered antegrade into the root if there is no significant aortic regurgitation (AR) and directly into the coronary ostia or retrograde if there is predominant AR. After the heart is arrested, the main pulmonary artery is divided anteriorly and obliquely to the left at the level of the bifurcation. The pulmonary valve is then inspected for any defects. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

3 If the pulmonary valve appears normal, the pulmonary artery is completely transected, and the surrounding adventitial tissue is mobilized using cautery and sharp dissection proximally, down to the level of the right ventricular muscle. The excision of the pulmonary autograft from the right ventricular outflow tract is then completed. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

4 The right ventricular wall is incised first anteriorly, with the position of this incision carefully chosen to be below the sinuses of the pulmonary valve. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

5 The incision is carried medially and laterally towards the ventricular septum and an infundibular muscle flap is created based on the expected depth of the ventriculoplasty that will be filled in by RV freewall muscle, the pulmonary valve is “enucleated” from the right ventricular outflow tract posteriorly. This maneuver prevents injury to the left anterior descending artery and the first septal perforator branch. We prefer to use cautery to remove posterior attachments of the pulmonary valve. This coagulates small vessels found in the area and prevents bleeding that may be difficult to control at a later time. If the plan is to repair the aortoventriculoplasty with a prosthetic patch, the extent of the infundibular muscle flap may be minimized. Once the pulmonary autograft is removed, the right ventricular muscle rim, with exception of the infundibular flap, is trimmed to within 3 to 4 mm of the valve and thinned to prevent subaortic narrowing once it is sewn into the LVOT. Infants with complex LVOTO often have significant pulmonary hypertension and PV hypertrophy, making debridement of the thick RV muscle necessary. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

6 After the autograft preparation is completed, attention is directed to the aorta and the aortic valve. The aorta is divided distally above the commissural attachments. If an arch defect, such as a coarctation or an interrupted aortic arch, is present, it is repaired often with a combination of primary anastomosis and homograft patch augmentation to create a good size match between the autograft and the distal aorta. Discrepancy at the initial suture line can cause dilation of the sinotubular junction if too large and stenosis with accelerated autograft valve failure if too small. Aortic buttons containing the coronary artery ostia are then excised and mobilized. The proximal aortic wall is removed down to 3 to 4 mm from the base of the coronary sinuses. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

7 The next step of the procedure is determined by the size discrepancy between the pulmonary autograft and the aortic annulus. If the size difference is only minor, aortic valve removal alone or an incision across the annulus such as the one used for Nicks valvuloplasty, may open the root sufficiently. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

8 If the aortic annulus requires more significant enlargement, the Ross-Konno procedure is performed. The septum is inspected, and the extent of the subaortic stenosis is determined. The aortic annulus and the ventricular septum are incised 4 to 5 mm to the left of the right coronary ostia or between the commissural attachments of the left and right coronary leaflets. This incision extends in an oblique and almost transverse direction, to the left of the conal papillary muscle of the tricuspid valve, thus avoiding an injury to the conduction tissue. The incision into the septum is carried down to just below the level of the subaortic stenosis. Any associated abnormal tissue, such as endocardial fibroelastosis or hypertrophied muscle is resected at this point. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

9 The pulmonary autograft is then sized to the left ventricular outflow tract. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

10 If the aortic annulus requires significant enlargement or the septal incision is too long to use the infundibular muscle flap, the septal defect is repaired with a v-shaped prosthetic patch. The autograft is then anastomosed to the aortic annulus posteriorly and to the superior edge of the patch. If the septal defect is small, it can often be then repaired with the infundibular muscle flap. In infants with an associated conoventricular VSD, use of the infundibular muscle flap is avoided, because the thickness and the need to suture to the TV annulus can cause inflow obstruction to the PV. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

11 The pulmonary autograft is anastomosed to the LVOT with a running absorbable suture, positioning the autograft so that the posterior sinus of the pulmonary autograft becomes the left coronary sinus and the infundibular muscle fits into the ventriculoplasty. After the first suture line is completed, the proximal aortic wall remnant is oversewn over this anastomosis with another running suture to aid hemostasis. In addition, this maneuver may potentially prevent late annular dilatation. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

12 The positions of the coronary arteries are determined, and, after suitable openings are excised in the pulmonary artery, the coronary ostia are anastomosed to the pulmonary artery with fine monofilament suture. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

13 Finally, after being trimmed to appropriate length, the distal pulmonary artery of the autograft is sutured to the aorta. Reinforcement of the distal suture line with a strip of prosthetic material is sometimes used in older patients to prevent dilation of the sino-tubular junction. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

14 The final segment of the procedure involves the right ventricular outflow tract reconstruction, more commonly using a pulmonary allograft. We routinely try to use the largest possible allograft that will fit in the chest to minimize the need for future replacement. Most infants who come to autograft root and Ross-Konno root replacement have some degree of arch and annular hypoplasia, in which case the pulmonary autograft will be significantly larger than the native aortic annulus and the ascending aorta. After the LVOT is reconstructed with the autograft, the location of the pulmonary bifurcation tends to be posterior to the neoaorta. Therefore, to prevent any allograft kinking, coronary artery compression, or anastomotic stricture, it is advisable to extend the opening in the pulmonary bifurcation onto the left pulmonary artery. The homograft is sutured distally to the pulmonary bifurcation with a continuous nonabsorbable suture, and proximally to the right ventricular outflow tract in a similar fashion. However, because of the proximity of the septal perforating branches of the LAD, the posterior sutures are taken only through the endocardium and partial thickness of the myocardium so as not to compromise the septal blood supply. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

15 Finally, because the autograft tends to be much larger than the original aortic annulus, it encroaches onto the right ventricular outflow tract. The allograft then ‘wraps’ itself around the pulmonary autograft and the posterior proximal suture line will be placed onto or near the autograft annulus. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions

16 The pulmonary homograft is usually of sufficient size that additional patch augmentation of the RVOT is rarely necessary. After completion of all of the suture lines, the cross-clamp is removed. The patient is then rewarmed and weaned from bypass. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 195-206DOI: (10.1053/otct.2002.36324) Copyright © 2002 Elsevier Inc. Terms and Conditions