Konno Procedure (anterior aortic ammlar eldargement)
for Mechmfical Aortic Valve Replacement
Hiromi Kurosawa
ortic a n n u l a r enlargement is f r e q u e n t l y ncces-
A .sary for the young patient with a small aortic
annulus undergoing mechanical valve r e p l a c e m e n t .
The Konno p r o c e d u r e was i n t r o d u c e d to allow aortic
valve r e p l a c e m e n t with an a d e q u a t e sized mechanical
valve for patients with a small aortic annulus. 1 A
h e a r t with c o n c o r d a n t a t r i o v e n t r i c u l a r and v e n t r i c u -
loarterial relation has an anatomical benefit w h e r e b y
the left v e n t r i c u l a r outflow tract makes a right angle
with the right v e n t r i c u l a r outflow tract. T h e r e f o r e , a
longitudinal incision in the aortic root and a trans-
188 Operative Techniques in Thoracic attd Cardiovascular Surgery, Vol 7, No ,l (November), 2002: pp 188-19,1.
verse incision in tile right v e n t r i c u l a r outflow tract
make a straight line. W h e n an aortic valve replace-
ment is n e c e s s a r y in c o m b i n a t i o n with a n n u l a r en-
largement the Konno p r o c e d u r e is the surgery of
choice.
Using standard cardiopuhnonary bypass with mod-
erate hypothermia and antegrade and/or retrograde
cohl cardioplegia, the aortic valve is inspected through
a longitudinal incision in the aortic wall. If the valve is
not repairable, it is excised for valve replacement and
the annular size is measured.
KONNO PROCEDURE 189

SURGICAL TECIINIQUE

Incisions i t e ~ ~
vPaUlvm~
~ . ~ ~ A /,,o rInciSi;c~:~t~alve

Tricuspid
, ~1~ v
valve

{ arte~.(~i. ` 9 ,~::71;i,:.';;/,:7t,7.~qi,:::i.)
'~i

I,'li I,-,,
~.~ .
,al t 1 ~7.. i~ }li " I A.,.~ ~ _ ~..~7~.1 -r-....~,~-..

1 If the anniilar size is too snlall for at] adequate size

prosthetic valve, tile longitudinal incision is anteriorly ex-
tended from the right coronary sinus to tile right ventricular
outflow tract. The incision is just to the right of the anterior
comnlissure of the aortic valve and is remote fronl the right
coronary orifice.
2 A longitttdinal incision is extended towards the aor-
toventricular junction orl the anterior wall of the ascending
aorta. A transverse incision is placed on the free wall of the
right ventricular outflow tract beneath the lmhnonary valve.
Boll] iilcisions meet in a straight li.e at tile aortoventricular
jimction.

Pulmonaryvalve Infundibularset)turn

itricle

annulus

3 Tile ventriculoinfimdiliular fohl and the aortic anntd.s are incise(I between the aortic wall incision and the right
vcntricular fi'ec wall incision. Tile incision is extended into tile inf.ndilmlar septum 5 to 7 mm underneath the ])ulmonary
valve.
190 IIIROM! KUROSAWA

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 infundilmlar
septum is incised, a large enough sizer can be inserted
into the enlarged left ventricular outflow tract. Because
the infimdibular septum incision is extended only to the
middle of the infundilmlar septum and does not reach
to the anterior septum, clamagc to the first septal
branch of tile left anterior descending coronary artery
shouhl be prevented.

/"
f

Tile incised vcntricular septunl is

usually two layers and thick. The first
plcdgeted suture is transmurally placed
through the thick ventricular septum from
left to right at the end of the infundilmlar
scptal incision (Fig 5a).
All pledgcted suturcs along tile incised
vcntricular scptum are transmurally
stitched through tile thick scptunx from tile
left vcntricular sidc to tile right (Fig 5b).
Thus, all pledgets arc located on tile left
side of the scptum. A transitional suture is
placed at tile junction of tile infimdibular
ventricular scptum, tile ventriculoinfnn-
dilmlar fohl and the aortic wall.
KONNO PROCEDURE 191

6 A comI)ositc patch made of Dacron (DuPont, Wilming-

ton, DE) and l)rcscrvcd xcnollericardium is used for aorto-
vcntriculol)lasty. All transmural plc,Igctcd sutures arc
l)assed through the patch and tied. The ventricular part of
the aorto-ventriculol)lasty 1latch is fitted on the ventricular
sel)lal incision. Then a continuous suture reinforces the in-
terrul)ted pledgeted sutures of the ventriculoplasty l)atch.

7 At tile beginning of tile

sutures for aortic valve rc-
l)laccmcnt, one needle of tran-
sitional suture (#1 ill Fig 7a)
from the aortic annulus to tile
patch is passed scquentially
through tile aortic ammlus,
tile vcntricular scptmn and
the patch at the junction of
tile vcntricular sel)tum and
tile aortic anmdus (Fig. 7b).
This needle is then passed
through tile patch from out-
side to inside. The second su-
ture is passed through the aor-
tic annulus and the third su-
ture is passed through the
patch.

Second needle
of #2 suture
192 ltlltOMl KUROSAWA

8 All sutures are stitched through the aortic annulus or the l/atch. Two transitional sutures from tlle junction between the
aortic annulus and thc ventricular sel)tum to tile l)atch arc placed as well. Plcdgetcd sutures along the aortic annulus are
placed in tile usual fashion for aortic valve rcl)lacemcnt.

j"
~f

- ~ Valve

][0 The fact that one-third of tile valve annulus is

9 A hi-leaflet mechanical valve is inserted in the enlarged sutured to the patch indicates 1.5 times enlargement of tile
aortic annuhls and tile sutures along the aortic annulus are aortic annulus. All sutures are tied and valve rcl~laccmcnt is
tied. finished at the enlarged aortic annulus.
KONNO I'ROCEDURE 193

1 1 The aorto-ventriculoplasty patch bulges 1,ccause of tile large mechanical vah-e (Fig 11).

A Se
sul

Vah
suture

13 A right vcntricular lmtch is trimmed in tile shape of

12 A transitional suture is stitched through tile ven-
triculoinfimdilmlar fohl, aortic wall, and patch (Fig 12a).
During this suture, a plcdgct is placed on the right ven-
tricular side of tile ventriculoinfundibular fohl. A composite
patch is sutltrcd with tire aortic wall by running suture (Fig
a crescent. The suture line of the right ventricular patch is
distal to tile suture line of tile mechanical valve on tile
aorto-ventriculoplasty lmtch. Tire right vcntricular patch is
sutured with the aorto-ventriculoplasly patch and then with
tire free wall of tile right ventricular outflow tract by running
51ttllr~.

12b).
194
Aorto-w
patch
vena cava
14 The Konno lWOCCdureis now complete.
COM31ENTS
After the Ross procedure'-' was revived in the 1980s and
aortic and imlmonary homografts became available,
the Ross procednre evoh'ed to be the procedure of
choice for yonng patients who need aortic vah'e re-
placement with annular enlargetnent. Therefore, the
classic Konno procedure is not nsually the procedure of
first choice for aortic annular enlargement in chihlren.
However, on occasion, homografts may be unavailalde
for right ventricular tract reconstruction. Another sit-
uation where the classic Konno procedure may be pre-
ferred is in the patient who has previously undergone
closure of a subarterial ventrieular septal defect close
to the 1)uhnonary annulus. Under these circumstances
the pulmonary valve may not be suitable for use in a
Ross procedure.
The concel)t of the Konno procedure in which the left
ventricular outflow tract is enlarged by an incision
from the aortic root into tile left ventricular outflow
tract has 1)een applied in conjunction with tile Ross
procedure and has been called the Ross-Konno l)roce-
( h i r e .3
The Konno aortoventriculoplasty has been reportcd
to be a good surbdcal option for complex left ventricular
outllow tract obstruction. Freedom from reoperation
for the mechanical valve has been reported as 80% at
IlIROMI KUROSAWA
r f-
/
/
s
Rt. atrium
10 )'cars and 52% at 15 years. In the experience of the
Heart Institute of Japan, 60 patients underwent a
Konno procedure with a mechanical valve between May
1984 and December 2000. The ages ranged from 2 to 37
years ohl with an average age of 11.6 years. There were
no hospital deaths with five late deaths. There have
been only two reoperations.
REFERENCES
1. Konno S, hnai Y, Iida Y, ct ah A new method for prosthetic valve
replacement in congenital aortic stcnosis associated with hypoldasia of
the aortic valve ring. J Thorac Cardiovase Surg 70:909-917, 1975
2. l{oss DN, Jackson M, Davis J: Pulmonary autograft aortic valve replace-
ment: Long term resuhs. J Card Surg 6:529-33, 1991
3. Rcddy VM, Rajasinghe IIA, Teitel DF, llaas GS, Ilanley FL: Aortoven-
triculol,lasty with the pyhnonary autograft: The "Ross-Konno" l,roce-
dure. J Thorae Cardiovase Surg 111:158-67, 1996
91. Erez E, Kantcr KR, Tam VKII, Williams WII: Konno aortoventrieulo-
plasty in ehihlren and adolescents: From prosthetic valves to the ]loss
operation. Ann Thorae Surg 74:122-6, 2000
From the Department of Cardiovascular Surgery, The lleart Institute of Japan,
Tokyo Women's Medical University, Tokyo, Japan
Address reprint requests to ltiromi Kurosawa, MD, Department of Cardiovas-
cular Surgery, The tleart Institute of Japan, Tokyo Women's Medical University,
8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan.
Copyright 2003, Elsevier Science (USA). All rights reserved.
1522-2912/03/0701-0001535.00/0
doi:10.1053/otct.2002.36323