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

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 through an anterior septoventriculoplasty, using a single pericardial patch, followed by composite aortic valve-graft root replacement. Postoperative outflow tract geometry and valvular physiology were compared against preoperative measurements using echocardiography and computed tomographic angiography. Clinical outcomes at 2 years were assessed.

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

Conclusions: The BeSPoKE 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.