Modified-Bentall Single-Patch Konno Enlargement Technique for Aortic Stenosis and Prosthesis-Patient Mismatch

Eric E Roselli; Benjamin P Kramer; Matthew A Thompson; Julie Ngauv; Abigail M Snyder; Jennifer Hargrave; Leonardo Rodriguez; Haytham Elgharably; Kenneth McCurry; Michael Z Tong; Patrick R Vargo; Eugene H Blackstone

doi:10.1016/j.athoracsur.2024.10.033

Modified-Bentall Single-Patch Konno Enlargement Technique for Aortic Stenosis and Prosthesis-Patient Mismatch

Ann Thorac Surg. 2024 Dec 7:S0003-4975(24)01040-3. doi: 10.1016/j.athoracsur.2024.10.033. Online ahead of print.

Affiliations

¹ Aortic Center and Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland Clinic, Cleveland, OH. Electronic address: [email protected].
² Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
³ Aortic Center and Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Cardiothoracic Anesthesiology, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
⁴ Aortic Center and Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
⁵ Aortic Center and Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
⁶ Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland Clinic, Cleveland, OH.

PMID: 39653107
DOI: 10.1016/j.athoracsur.2024.10.033

Abstract

Background: Aortic stenosis and prosthesis-patient mismatch complicate surgery for patients with small left ventricular outflow tracts. We present outcomes of a modified-Bentall single-patch Konno enlargement (BeSPoKE) technique for complex left ventricular outflow tract obstruction in adults.

Methods: The BeSPoKE technique facilitates a true outflow tract enlargement via an anterior septo-ventriculoplasty, using a single pericardial patch, followed by composite aortic valve-graft root replacement. Postoperative outflow tract geometry and valvular physiology were compared to preoperative measurements using echocardiography and computed tomographic angiography; two-year clinical outcomes were assessed.

Results: From October 2017 to March 2022, 25 adults (median age 60 years; 84% female) underwent a BeSPoKE repair. Mean preoperative aortic valve gradient was 44 ± 19mmHg. Twenty-one (84%) patients had previous aortic valve replacements with prosthesis-patient mismatch; median implant size preoperatively was 19mm. Postoperatively, all patients received a prosthesis of at least 21mm, with a median upsizing of 2 (15^th-85^th Percentile, 2-3 sizes). Mean postoperative aortic valve gradient was 8.5 ± 4.1mmHg (P<.001); mean 2-year gradient was 8.3 ± 1.3mmHg. All patients with bioprosthetic replacements qualified for future transcatheter valve replacements. Postoperative complications included atrial fibrillation (9; 36%) and complete heart block requiring pacemaker placement (8; 32%). There were zero operative mortalities and no reoperations reported. There were 2 late non-cardiac-related deaths; 2-year survival was 92%.

Conclusions: The modified-Bentall single-patch Konno enlargement technique facilitates larger prosthesis placement, improves hemodynamics, and enables future transcatheter reinterventions. This approach is a safe treatment for complex left ventricular outflow tract obstruction and prosthesis-patient mismatch in adults.