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Long-Term Results of the Konno Procedure for Complex Left Ventricular Outflow Tract Obstruction

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Objective:
To determine the long-term clinical and echocardiographic outcome after the Konno-Rastan aortoventriculoinfundibuloplasty (Konno procedure) for complex left ventricular outflow tract (LVOT) obstruction.
Methods:
The records of 53 patients (pt) who underwent the Konno procedure between January 1, 1980 and January 1, 2004 were reviewed. Excluded from analysis were 5 other pt who underwent the Ross-Konno procedure.
Results:
The mean age at operation was 19 years (range, 1-65 yr) and there were 27 (51%) males. Prior to the Konno procedure, 66 operations had been performed in 41 (77%) pt to relieve LVOT obstruction. Indications for the Konno procedure were complex subaortic / tunnel stenosis in 22 (41%), multilevel LVOT obstruction in 20 (38%) and aortic valve stenosis / hypoplasia in 11 (21%). A total of 33 (62%) pt had greater than NYHA class I symptoms preoperatively. A mechanical aortic valve was implanted in 40 (75%), a homograft in 10 (19%) and a biological prosthesis in 3 (6%). Mortality at 30 days was 8% (n=4) (95% confidence interval (CI) 2-18%). Nonfatal complications included heart block (7), sepsis (2), bleeding (2), respiratory failure (1) and renal failure (1). Follow-up ranged from 0 to 21 yr (median 5.2 yr). Mortality at 10 yr was 16% (95% CI 4-26%). The only risk factor for overall mortality identified was longer bypass time (HR=2.3/hour, p=0.02). The cumulative probability of aortic valve reoperation was 17% (95 % CI 4-28%) at 5 yr and 40% at 10 yr (95% CI 17-57), occurring in 14 pt at a median of 4.3 yr. Indications for aortic reoperation were valve stenosis in 7, regurgitation in 4 and endocarditis in 3. Causes of other cardiac reoperations were ventricular septal defect in 2 and pulmonary valve regurgitation in 1. A total of 102 follow-up echos were available for review in 46 pt and were divided into categories from the date of operation: <1year, 1-3 yr and 3-5 yr. The average LVOT gradient (mmHg) at 1 yr was 19 (n=9), 13 (n=9) at 1-3 yr and 13 (n=5) at 3-5 yr. Pulmonary regurgitation was detected in 4 pt and was mild in 1, moderate in 2 and severe in 1. At the date of last contact, 43 pt were still alive, and 37 were in NYHA class I or II.
Conclusions:
The Konno procedure is durable, allowing both long-term reduction of LVOT obstruction and improvement in functional class. Prosthetic aortic valve and, infrequently, native pulmonary valve complications may necessitate reoperation.
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