DEPT. OF CARDIOVASCULAR SURGERY, SHAHEED RAJAEE CARDIOVASCULAR MEDICAL CENTER, MELLAT PARK, VALI ASR AVE., TEHRAN, IRAN
Background: An aggressive resection in complex left ventricular tract obstruction (LVOTO) may injure the conduction system and create a ventricular septal defect (VSD). On the other hand, incomplete resection results in residual gradient across the aortic valve. In addition, aortic valve replacement (AVR) in the small aortic root may be impossible or associated with stenosis of the left ventricular outflow tract. The purpose of this article was to evaluate the early and mid-term results of the Rastan-Konno aortoventriculoplasty to address these problems.
Methods: Retrospective analysis of pertinent data for all the patients who underwent the Rastan- Konno procedure between 1997 and 2003 at our department was performed. Twenty-four patients aged 5-31 years (mean 13.2±7) underwent the Rastan-Konno procedure for severe LVOT obstruction (15 cases) and enlargement of small aortic root (9 cases). The patients had previously undergone LVOT resection (n=6), surgical valvotomy (n=6), AVR (N=2) and balloon valvuloplasty (n=6).
Results: The mean preoperative peak systolic gradient across the LVOT was 90.5±34.8 mmHg (range 30-150), which was reduced to 28.1±17.7 mmHg (range 0-66), postoperatively (p<0.001). Permanent heart block developed in 3 patients (12.5%), and a small residual VSD was seen in one patient. There were no cases of prosthetic valve malfunction, permanent paravalvular leak or acute mediastinitis. Hospital mortality rate was 12.5%. One of the patients died due to low cardiac output syndrome, and another patient died following excessive generalized mediastinal bleeding. The third mortality was after a cerebrovascular accident on the 7th postoperative day. There were no deaths during the follow-up (mean 22.6±14.3 months).
Conclusion: Recurrent LVOT obstruction is common after the resection of simple LVOT obstruction; in complex forms, a satisfactory reduction of LVOT gradient is more difficult with only myotomy or myomectomy. The Rastan-Konno aortoventriculoplasty can effectively relieve complex and recurrent LVOT obstruction with minimal morbidity and acceptable mortality rate. In addition, we believe that this procedure can be of benefit for AVR in patients with a small aortic root.