Title
WHEN TIME TELLS: A JOURNEY THROUGH LONG-TERM COMPLICATION OF THE ROSS-KONNO PROCEDURE
Introduction
Ross-Konno procedure is a complex surgery where the patient's aortic valve is replaced with their own pulmonary valve & pulmonary valve with a donor/mechanical valve for complex left ventricular outflow tract (LVOT) obstruction. It also involves enlarging the aortic root & ventricular outflow tract by incising the septum. Compared to other techniques, such as the Nicks, Manouguian, or Yamaguchi procedures, the Konno procedure provides nearly unlimited LVOT enlargement, making it essential for severe subaortic lesions, as it allows for implantation of larger prostheses. It also provides excellent hemodynamics and reduced risk of endocarditis and thromboembolism.
Clinical Case
48 year old male presented with dyspnea and bilateral lower limb edema for several months. Social history was significant for alcohol and marijuana use. Surgical history was significant for Ross-Konno procedure 30 years ago. Initial heart rate was 81, blood pressure was 141/37, afebrile, respiratory rate of 16 and saturating well on room air. Pro BNP was elevated to 7543. EKG showed left ventricular hypertrophy & right bundle branch block. Initial echo showed moderately reduced left ventricular systolic function with ejection fraction of 31-35%, severe pulmonic and aortic valve regurgitation (AR) with an eccentric aortic regurgitant jet, non-coaptation of the normal opening aortic leaflets, thickened aortic annulus, severely dilated sinuses of valsalva, normal right ventricular size and systolic function, normal pulmonary artery systolic pressure and trivial pericardial effusion. He underwent resternotomy & aortic root replacement with 23 mm Edwards pericardial valve & required coronary artery bypass grafting of left anterior descending and right coronary artery with 2x saphenous venous grafts. He required e
xtracorporeal membrane oxygenation and intra-aortic balloon pump simultaneously and vasopressors (norepinephrine, vasopressin, dobutamine, and epinephrine). The course was complicated with self-limiting ventricular tachycardia and the patient was started on amiodarone drip. The course was complicated by stroke and excessive bleeding. His repeat echo after 3 weeks showed moderate to severely decreased left ventricular systolic function with ejection fraction of 26-30%, abnormal septal motion consistent with conduction abnormality and post-operative status, mildly reduced right ventricular function, mild dilation of right atrium, severe pulmonary regurgitation, moderate pulmonary stenosis and bioprosthetic aortic valve with low dimensionless index of 0.25 suggestive of stenosis without regurgitation appreciated.
Discussion
Although many studies have highlighted satisfactory outcomes after the Ross-Konno procedure, there are various long-term complications that include progressive aortic root enlargement causing AR, pulmonary homograft dysfunction, & arrhythmias. Recent studies have shown increasing enlargement of the aortic root especially when there was a mismatch of the aortic & pulmonary roots at the time of the initial surgery, causing new-onset progressive aortic regurgitation requiring reoperation in some cases. One study highlighted risk factors for reoperation that included age at the time of initial procedure >8.6 years, aortic annulus diameter >24 mm, and Ao/PA ratio >1.2. This case highlights aortic root enlargement & severe AR necessitating reoperation, which is a long-term complication due to the Ross-Konno procedure. Lifelong monitoring is essential to manage & prevent adverse outcomes