Konno Procedure (anterior aortic annular enlargement) for Mechanical Aortic Valve Replacement  Hiromi Kurosawa  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 7, Issue 4, Pages 188-194 (November 2002) DOI: 10.1053/otct.2002.36323 Copyright © 2002 Elsevier Inc. Terms and Conditions

1 If the annular size is too small for an adequate size prosthetic valve, the longitudinal incision is anteriorly extended from the right coronary sinus to the right ventricular outflow tract. The incision is just to the right of the anterior commissure of the aortic valve and is remote from the right coronary orifice. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

2 A longitudinal incision is extended towards the aortoventricular junction on the anterior wall of the ascending aorta. A transverse incision is placed on the free wall of the right ventricular outflow tract beneath the pulmonary valve. Both incisions meet in a straight line at the aortoventricular junction. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

3 The ventriculoinfundibular fold and the aortic annulus are incised between the aortic wall incision and the right ventricular free wall incision. The incision is extended into the infundibular septum 5 to 7 mm underneath the pulmonary valve. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

4 The Konno incision is 2 to 3 mm to the right of the anterior commissure of the aortic valve and remote from the right coronary orifice. After the infundilbular septum is incised, a large enough sizer can be inserted into the enlarged left ventricular outflow tract. Because the infundibular septum incision is extended only to the middle of the infundibular septum and does not reach to the anterior septum, damage to the first septal branch of the left anterior descending coronary artery should be prevented. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

5 The incised ventricular septum is usually two layers and thick. The first pledgeted suture is transmurally placed through the thick ventricular septum from left to right at the end of the infundibular septal incision (Fig 5a). All pledgeted sutures along the incised ventricular septum are transmurally stitched through the thick septum from the left ventricular side to the right (Fig 5b). Thus, all pledgets are located on the left side of the septum. A transitional suture is placed at the junction of the infundibular ventricular septum, the ventriculoinfundibular fold and the aortic wall. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

6 A composite patch made of Dacron (DuPont, Wilmington, DE) and preserved xenopericardium is used for aortoventriculoplasty. All transmural pledgeted sutures are passed through the patch and tied. The ventricular part of the aorto-ventriculoplasty patch is fitted on the ventricular septal incision. Then a continuous suture reinforces the interrupted pledgeted sutures of the ventriculoplasty patch. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

7 At the beginning of the sutures for aortic valve replacement, one needle of transitional suture (#1 in Fig 7a) from the aortic annulus to the patch is passed sequentially through the aortic annulus, the ventricular septum and the patch at the junction of the ventricular septum and the aortic annulus (Fig. 7b). This needle is then passed through the patch from outside to inside. The second suture is passed through the aortic annulus and the third suture is passed through the patch. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

8 All sutures are stitched through the aortic annulus or the patch. Two transitional sutures from the junction between the aortic annulus and the ventricular septum to the patch are placed as well. Pledgeted sutures along the aortic annulus are placed in the usual fashion for aortic valve replacement. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

9 A bi-leaflet mechanical valve is inserted in the enlarged aortic annulus and the sutures along the aortic annulus are tied. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

10 The fact that one-third of the valve annulus is sutured to the patch indicates 1.5 times enlargement of the aortic annulus. All sutures are tied and valve replacement is Finished at the enlarged aortic annulus. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

11 The aorto-ventriculoplasty patch bulges because of the large mechanical valve (Fig 11). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

12 A transitional suture is stitched through the ventriculoinfundibular fold, aortic wall, and patch (Fig 12a). During this suture, a pledget is placed on the right ventricular side of the ventriculoinfundibular fold. A composite patch is sutured with the aortic wall by running suture (Fig 12b). Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

13 A right ventricular patch is trimmed in the shape of a crescent. The suture line of the right ventricular patch is distal to the suture line of the mechanical valve on the aorto-ventriculoplasty patch. The right ventricular patch is sutured with the aorto-ventriculoplasty patch and then with the free wall of the right ventricular outflow tract by running suture. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions

14 The Konno procedure is now complete. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 188-194DOI: (10.1053/otct.2002.36323) Copyright © 2002 Elsevier Inc. Terms and Conditions