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Background. The most common forms of congenital and acquired obstructions of the left ventricular outflow tract (LVOT) are the valvular aortic stenosis, the congenital tunnel-like obstruction, the hypertrophic obstructive cardiomyopathy and finally the prosthetic-patient mismatch (PPM) following aortic valve replacement. The last one is most probably under-estimated and under-treated. Here, we report our experience with the Konno anterior aorto-ventriculoplasty in adult patients suffering from prothesis-patient mismatch.
Patients. Between 2005 and 2020, 8 patients received a classical Konno anterior enlargement of the aortic anulus to treat a typical PPM (n=5) or another complex obstructing pathology of the LVOT (n=3). Median age was 42.5 years and 5 patients were female. All patients suffered from exercise dyspnea NYHA functional class III or IV. In addition to the Konno procedure, 3 patients underwent mitral valve replacement (n=2) or repair (n=1). Two patients received tricuspid anuloplasty to treat severe concomitant tricuspid regurgitation. All patients had undergone at least one previous operation, 3 patients had 2 prior procedures in their medical history and 1 patient was operated for the fifth time.
Results. All patients survived the operation. One younger patient suffering from Werners' type of progeria died in-hospital on postoperative day 45 following prolonged hemodynamic failure. She also had developed thrombosis of the mechanical mitral prosthesis, underwent thrombectomy and extracorporeal membrane oxygenation support (ECMO) but did not recover. One patient required a double chamber pacemaker implantation because of persistent atrio-ventricular block III. All surviving patients had very satisfactory postoperative hemodynamic patterns across the LVOT.
Conclusion. The Konno anterior aorto-ventriculoplasty is a very efficient method to adequately enlarge the LVOT, independently from the initial pathology. This technique is only rarely used because it is considered as a complex intervention. However, this type of enlargement usually allows the insertion of a larger prosthesis than after a simpler Manougian or Nicks posterior anulus enlargement. For adult patients with severe PPM or other forms of complex LVOT obstruction, the Konno intervention is a valuable option that should be offered to these patients.
In fetuses with complex type of congenital heart disease (CHD), impaired brain growth and brain development starts in utero. A complex interplay between heart, brain, and placenta takes place within the second and third trimester of pregnancy. Altered fetal cardiovascular hemodynamics due to the type of CHD leads to an altered cerebral and placental perfusion, both factors contributing to maturational delay of body and brain development. Impaired cerebral perfusion, oxygenation, and nutritive energy supply affects brain growth and leads to brain developmental delay of 3-4 weeks until birth. Comparable to the altered brain development in pre-terms, pathogenic mechanisms lead to an encephalopathy of CHD on a micro- and macrostructural level. After birth palliative or corrective cardiac surgery is needed, which further contributes to the brain maturational delay with consequences on the neurodevelopmental outcome.
