Cardiovascular Journal of Africa: Vol 26 No 1 (January/February 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015 AFRICA e1
Case Report
Five-year follow up of Konno aortoventriculoplasty for
repeat aortic valve replacement in an adult patient
Ibrahim Uyar, Tolga Demir, Gunseri Uysal Uyar, Engin Tulukoglu, Ali Ihsan Parlar, Omer Isık
Abstract
Konno aortoventriculoplasty (AVP) is performed for various
types of left ventricular outflow tract obstruction. We report
on a 32-year-old woman who had undergone double valve
replacement five years earlier. She presented with increased
interventricular septum thickness, small aortic root and gradi-
ent across the aortic mechanical valve. We performed Konno
AVP with repeat aortic valve replacement (AVR). The control
echocardiography showed no significant residual gradient.
Konno AVP with repeat AVR may be safely performed with
satisfactory results.
Keywords: aortic valve replacement, aortoventriculoplasty,
Konno, re-operation
Submitted 28/4/14, accepted 18/9/14
Cardiovasc J Afr 2015; 26: e1–e3
DOI: 10.5830/CVJA-2014-059
Aortoventriculoplasty (AVP), also known as the Konno
procedure since initial descriptions of the technique in 1975,1
has proven to be safe and effective in relieving complex left
ventricular outflow tract (LVOT) obstruction in a number of
studies.2,3 This procedure allows one to enlarge the aortic root
and increase the size of the aortic valve implanted.
In this report, we present five-year follow up of our experience
with the use of the anterior root-enlargement technique (Konno
AVP) in conjunction with repeat aortic valve replacement (AVR)
in an adult who had undergone mitral valve replacement (MVR)
and AVR five years earlier.
Case report
A 32-year-old woman had had AVR (size no 19, St Jude Medical,
Inc, St Paul, MN) and MVR (size no 23, St Jude Medical,
Inc, St Paul, MN) due to rheumatic heart disease five years
earlier. She was admitted to our clinic with a month’s history of
fatigue, dyspnoea, initially on intense effort and subsequently
on minimal exertion. The symptoms had worsened during
the last few days, leading to dyspnoea at rest with features of
orthopnoea, coughing with foamy expectoration, weakness and
coldness. She was classified as New York Heart Association
(NYHA) functional class III.
On examination, cardiac auscultation revealed a reduced
second sound with no aortic closing click. Transthoracic (TTE)
and transoesophageal (TEE) echocardiographies revealed
increased interventricular septum thickness (17 mm), small
aortic root [1.9 cm (< 1 cm/m2)] and gradient across the aortic
mechanical valve (mean: 55 mmHg, peak: 110 mmHg), and
ejection fraction (EF) was 56%. The mechanical mitral valve
function was normal. We chose to perform the Konno AVP on
this patient.
Re-operation was performed via repeat median sternotomy.
Standard cardiopulmonary bypass (CPB) was established with
aortic and both vena caval cannulation. The ascending aorta and
pulmonary trunk were dissected and the position of the right
coronary artery was accurately identified. Systemic hypothermia
was maintained at 28°C and intermittent potassium-enriched
cold blood cardioplegia was used.
A vertical aortotomy was made and the valve was inspected.
After explanting the old valve substitute, excessive fibrotic
tissue was debrided. To relieve subvalvar obstruction and to
implant a new, larger prosthesis, an incision was made in the
right ventricular outflow tract, followed by an incision across the
aortic annulus into the ventricular septum to the left of the right
coronary artery ostium, as described by Konno et al.4 (Fig. 1).
A Dacron patch was tailored to fit the enlargement,
approximately 2 × 4 cm, and was positioned on the right side
of the septal opening, increasing the annular circumference
of 1.5 cm. A no 23 St Jude (St Jude Medical, Inc, St Paul,
MN) valve was then inserted on the patient’s annulus and its
Dacron extension (Fig. 2). After valve insertion, the Dacron
patch was used for ascending aorta enlargement. Finally, the
right ventricular outflow tract was closed with a Dacron patch
(Fig. 3).
Thepostoperativecoursewasuneventful.Anelectrocardiogram
showed sinus rhythm. On follow-up transthoracic TTE, the
gradient across the LVOT was below 20 mmHg and on the mitral
mechanical valve, the peak gradient was 4 mmHg.
The patient was discharged on the tenth postoperative day.
She was anticoagulated with warfarin, keeping the international
normalised ratio (INR) between 2.5 and 3.5.
Akut Kalp Damar Hastanesi, Izmir, Turkey
Ibrahim Uyar MD
Tolga Demir, MD
Gunseri Uysal Uyar, MD
Engin Tulukoglu, MD
Ali Ihsan Parlar, MD,
Omer Isık, MD