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Sinotubular JunctionAortic Annulus Aortic Cusps
Aortic
Sinuses
• It’s the bridge between the LV cavity and
the Asc. Aorta.
• It provides the supporting foundation for
the Ao. Leaflets.

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Too Small
Small Aortic Annulus
Too large
Aortic Aneurysm
Replacement
Valve sparing
• Remodeling
• Reimplantation
Bentall
• Mechanical
• Stented or
stentless
valve
Enlargement and replacement
• Ross – Konno
• Modified Ross Konno
Replacement
• Bentall procedure
• Ross procedure
Enlargement
• Ant. Procedure (Konno)
• Posterior Procedure
• (Nicks or Manouguian)
Apico – aortic valve conduit

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Mild > 0.85 cm2/m2
Moderate 0.65 – 0.85 cm2/m2
Severe < 0.65 cm2/m2

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Persistently high transvalvular pressure
Controversy regarding short
& long term mortality
Reduced
• LV mass regression
• Symptoms improvement
• Exercise tolerance
Hemolysis

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• Ao. Annulus < 19mm
• BMI > 1.9
• EOAI < 85cm2/m2
• Patient age
• Comorbid conditions
• Anatomy oftheaorticroot
• Surgeon’s judgment and experience
But this depends
on

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Nicks’ procedure Manouguians procedure
• Aortotomy to the middle of NNC.
• Extending across the annulus to the
ant. Mitral leaflet.
• V shaped Dacron patch to close the
defect and extends the annulus 2 –
3 cm.
• Aortotomy to the commissure
between the NCC and LCC.
• Extending just below the aorto-
mitral fibrous continuity.
• Tear drop Dacron patch is used

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Rastan Konno
Procedure
Morecommoninchildren.
Indicated when aortic annulus and left
ventricular outflow tract are narrow
(Congenital tunnel stenosis).
Longitudinal anterior aortotomy is
extended across anterior annulus and
inter-ventricular septum to open LVOT.
Incision extended to open RVOT.

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Dacron/ bovine pricardial patch is used
to enlarge LVOT and prosthesis is
inserted.
Second dacron/bovine pericardial
patch is used to close right ventricular
outflow incision.

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LVOT tunnel like.
Aortic regurgitation after balloon
angioplasty in neonatal age with small
annulus.
Mismatch in the aortic and pulmonary size.
Pulmonary autograft have the advantage of
• No anticoagulation
• Better hemodynamics
• Growth potential
Indications
 Rastan-Konno approach is
used to expose and open
LVOT.
 Pulmonary autogaft is
harvested and used as in
classical Ross procedure.

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Apico-aortic conduit
Indications
 Severe left ventricular hypertrophy.
 Diminutive left ventricular size.
 Diffuse thickness of the IVS.
 Multiple aortic valve replacements with
small aortic root.

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There is no cut off data to suggest the exact indication
for Ao. root enlargement.
Surgeon evaluation and experience are the main
important factors in decision making.
Presence of PPM may increase gradients and reduce
IEO but does not affect survival.

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Infant Children Adult
Small Ao. annulus Small Ao. annulus Small Ao. annulus
No LVOT
obstruction
LVOT
obstruction
No LVOT
obstruction
LVOT
obstruction
Large BSA
> 1.9
Small BSA
< 1.5
Ross
procedure Ross /
Konno
procedure
Ross
Procedure
Ross /
Konno
Or
Rastan /
Konno
Ross
procedure
Or
Homograft
Or
AVR + AVE
AVR

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