Konno Operation

History of Konno Operation

Aortic valve stenosis with small aortic annulus was a difficult clinical problem for standard prosthetic aortic valve replacement. In 1973, Konno performed a new operation of prosthetic aortic valve replacement on a 23-year-old woman with congenital aortic stenosis associated with hypoplastic aortic valve ring. This new method was published in the Journal of Thoracic and Cardiovascular Surgery in 1975. ² Konno described, “The procedure consists of a longitudinal incision in the aortic septum placed in the midportion of the two coronary ostia, a vertical incision in the outflow tract of the right ventricle to join the septal incision, prosthetic aortic valve replacement, and patch reconstruction of the outflow tracts of both ventricles by means of two layers of a fusiform Dacron patch.”^(p909) An enlargement of the left heart was achieved by an enlargement of the right heart. Since then, this procedure has been called “Konno operation.” ³

Technical Details of Konno Operation

The Konno operation is an aortic valve replacement with concomitant anterior aortic annular and left ventricular outflow tract enlargement of the hypoplastic aortic annulus and tunnel left ventricular outflow tract obstruction (LVOTO). ⁴ The incision from the aorta to the right ventricle is a daunting procedure for surgeon. A longitudinal incision on the anterior wall of the ascending aorta is extended toward the aortoventricular junction. 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 (Figure 2).

OPEN IN VIEWER

Figure 2.

Konno operation: a vertical incision (A) on the ascending aorta is followed by a transverse incision (B) on the right ventricular outflow tract. Adapted from Konno et al with permission from Elsevier. ²

The incision of the aorta is carefully extended to the right of the anterior commissure of the aortic valve and divides the hypoplastic aortic annulus. Therefore, the incision is remote from both right and left coronary orifices.

The incision is further extended into the infundibular septum across the ventriculo-infundibular fold beneath the pulmonary valve. The anterior wall of the ascending aorta and ventricular septum are widely opened by aortoventricular incision between the tricuspid and pulmonary valve (Figure 3). If the incision of the infundibular septum is close to the medial papillary muscle in the right ventricle, it could be close to not only the right bundle branch but also the anterior part of the left bundle branch on the left-side aspect of the ventricular septum. Because the incision of the infundibular septum is extended only to the middle of the infundibular septum and does not reach the anterior septum, a damage to the first septal branch of the left anterior descending coronary artery can be prevented (Figure 4). The incision from the aorta to the ventricular septum again must be a daunting procedure for surgeons. The procedure extending from the left to the right heart is really the fruit of innovative thinking. The triangle space of the incised infundibular septum is closed by an aortoventriculoplasty patch. All pledgeted sutures are transmurally stitched through the thick ventricular septum from the left to the right to prevent a leakage. Thus, all pledgets are located on the left side of the septum. If necessary, the ventriculoplasty patch is reinforced by a continuous suture.

OPEN IN VIEWER

Figure 3.

Anterior wall of the ascending aorta and ventricular septum are widely opened at once by aortoventricular incision between the tricuspid and pulmonary valve. Adapted from Konno et al with permission from Elsevier. ²

OPEN IN VIEWER

Figure 4.

Incision of ventricular septum: aortic incision is extended into the infundibular septum across the ventriculo-infundibular fold beneath the pulmonary valve. Adapted from Kurosawa. ⁴

During aortic valve replacement, the transitional suture #2 is very important. This suture is placed at the junction of the aortic annulus and the aortoventriculoplasty patch (Figure 5). The first needle of #2 suture without pledget is consecutively stitched through the aortic annulus, ventricular septum, and patch from in to out (see Figure 5A and arrow in Figure 5B). Then the first needle of #2 suture is turned and stitched through only the patch from out to in. Therefore, it looks like that the first needle of #2 is stitched only in the patch and the second needle of #2 is consecutively stitched in the patch, the ventricular septum and the aortic annulus. This transitional suture can prevent a perivalvular leakage. The #1 suture is stitched in the aortic annulus and #3 suture is stitched in the patch.

OPEN IN VIEWER

Figure 5.

Transitional suture. A, The first needle of #2 is stitched in aortic annulus from in to out (see arrow in B). B, The first needle of #2 suture is stitched from in to out through aortic annulus (arrow), ventricular septum, and patch. Then the first needle of #2 suture is turned and stitched from out to in through patch. #1 Suture is stitched in aortic annulus and #3 suture is stitched in patch. Adapted from Kurosawa. ⁴ .

After aortic valve replacement, the longitudinal aortic incision was covered by the superior part of the aortoventriculoplasty patch. The transverse incision of the right ventricular outflow tract is closed by another patch.

Surgical results of Konno operation are satisfactory. Sixty-three patients who underwent Konno operation at Tokyo Women’s Medical University from 1984 to 2007 were followed. There was one hospital death (myocardial infarction) and six late deaths (sudden death, 2; congestive heart failure, 2; infectious endocarditis, 1; and traffic accident, 1). The Kaplan-Meier survival rates including hospital mortality and late mortality were 91.9% at 10 years and 87.7% at 15 years, respectively. ⁵

Application of Konno Operation

The Konno aortoventriculoplasty is an excellent surgical option for complex LVOTO. ⁶ Modified Konno operation was introduced by Cooley and Garrett in 1986. ⁷ Left ventricular septoplasty was performed, preserving the aortic valve. Modified Konno operation has been applied for LVOTO after intracardiac repair of atrioventricular septal defect. ^8,9

Ross-Konno operation was introduced by Reddy et al in 1996. ¹⁰ They concluded that aortoventriculoplasty with the pulmonary autograft is an excellent alternative for young patients with complex LVOTO. They call this procedure as “Ross-Konno operation.” In Ross-Konno operation, there are two types of Konno incision. In the description by Reddy et al, ¹⁰ the aortoventricular incision, the so-called Konno incision (arrow A in Figure 6), was extended from the hypoplastic aortic annulus into the infundibular septum across the ventriculo-infundibular fold beneath the pulmonary valve as in the original Konno operation. However, a modified Konno incision (arrow B in Figure 6) is preferable. ¹¹ It is extended on the superior wall of the left ventricle where the pulmonary autograft has been harvested. This modified Konno incision should not endanger the coronary arteries, because both coronary arteries are already removed from the aorta. Conduction disturbance of the right bundle branch and superior branch of the left bundle branch can be safely prevented. Furthermore, the dysfunction of the ventricular septum can be minimized.

OPEN IN VIEWER

Figure 6.

Konno incision. Arrow A, Konno incision is extended from the hypoplastic aortic annulus into the infundibular septum across the ventriculo-infundibular fold above the medial papillary muscle as in the original Konno operation. Arrow B, A modified Konno incision is extended into the superior wall of the left ventricle where the pulmonary autograft has been harvested.

The Konno operation was also applied to the aortic valve replacement after arterial switch operation for the patient with small aortic annulus and unusual coronary anatomy (Figures 7 and 8). ¹² A girl in her infancy underwent arterial switch operation and closure of a large ventricular septal defect. The coronary anatomy was the so-called Shaher type 9, ¹³ in which the right coronary artery originated from the right-hand facing sinus and traversed the right ventricular outflow tract to the right. The left coronary artery originated from the left-hand facing sinus and posteriorly went around the pulmonary artery. After arterial switch operation, the right coronary artery coursed anteriorly in front of the pulmonary artery and the left coronary artery posteriorly went around the aorta to the left. Aortic regurgitation gradually developed. At the age of 16 years, she successfully underwent Konno operation with a large enough aortic valve for small aortic annulus and atrioventricular groove patch plasty ¹⁴ to prevent a damage of the right coronary artery (Figures 7 and 8).

OPEN IN VIEWER

Figure 7.

Konno operation and atrioventricular groove patch plasty: right coronary artery originated from the right-hand facing sinus and traversed the right ventricular outflow tract to the right. Left coronary artery originated from the left-hand facing sinus and posteriorly went around the pulmonary artery (Shaher type 9). After the arterial switch operation, right coronary artery traversed in front of the pulmonary artery and left coronary artery went around the aorta to the left. Konno operation and atrioventricular groove patch plasty were concomitantly performed.

OPEN IN VIEWER

Figure 8.

Konno operation and atrioventricular groove patch plasty after arterial switch operation for transposition of the great arteries with Shaher 9 coronary artery. A, Konno operation. B, Atrioventricular groove patch plasty. Adapted from Kosaka et al. ¹²

This concomitant surgery was also performed on a 20-year-old male who underwent arterial switch operation for transposition of the great arteries and Shaher type 4 ¹³ at the age of 4 months. Because of recurrent subaortic and pulmonary stenoses associated with new aortic valve regurgitation, resection of subaortic stenosis and a relief of the right ventricular outflow tract obstruction were performed at the age of 4 and 14 years, respectively. Conversion to original Jatene procedure was concomitantly performed at the age of 14 years. He eventually underwent Konno operation by using atrioventricular groove patch plasty to prevent a damage of the right coronary artery. He has been doing well.

If the coronary anatomy is most common as Shaher type 1, ¹³ in the transposition of the great arteries, Konno operation after arterial switch operation can be performed through a longitudinal incision on the anterior pulmonary trunk and on the right ventricle without a damage of coronary artery. Patch enlargement of the pulmonary trunk and the right ventricle can be achieved between the right and the left coronary arteries. In this situation, atrioventricular groove patch plasty is unnecessary.

In conclusion, the Konno operation is an effective and safe surgical option for the hypoplastic aortic annulus and tunnel LVOTO.