Left Ventricular Outflow Tract Anomalies

  • Viktor Hraška
  • Peter Murín


Congenital left ventricular outflow tract obstruction accounts for 10% of all congenital heart disease. For practical purposes, the site of obstruction is classified anatomically as valvar, subvalvar, or supravalvar, or as a combination of the three (multilevel stenosis).

The decision-making process and planning of operative care is complicated by the heterogeneous make-up of patients with left ventricular outflow tract obstruction. In neonates, the critical point is to decide whether biventricular repair is feasible. Patients with isolated stenosis and well-developed left ventricles are optimal candidates for biventricular repair. At the other end of the spectrum, a left ventricular outflow tract obstruction could be part of complex congenital cardiac malformations with a morphologically or functionally (endocardial fibroelastosis) borderline left ventricle, with multiple sequential outflow obstructions (Shone syndrome, hypoplastic left heart syndrome, etc.), when the single-ventricle pathway might be the optimal approach.

Growth, an active lifestyle with the appropriate activity level, and the difficulties in medical compliance represent another specific set of requirements posed by this subset of patients. In general, the prosthetic materials should not compromise cardiac growth and lifestyle. In particular, reconstruction of the aortic valve and pulmonary autograft procedure for replacement of the aortic valve and aortic root has dramatically changed the approach to children with congenital aortic valve disease and complex left ventricular outflow tract obstructions. On the other hand, in some children, the best alternative is to use a prosthetic valve or allograft, despite the well-known drawbacks of these procedures.


Aortic Valve Aortic Stenosis Aortic Regurgitation Left Ventricular Outflow Tract Obstruction Sinotubular Junction 
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Supplementary material

Clip 1: Preoperative echocardiogram.

Clip 2: An oblique, inverted–hockey stick–type of incision is made from the anterior aspect of the aorta towards the noncoronary sinus of Valsalva.

Clip 3: The morphology of the valve, the arrangement of the commissures, and localization of the false raphe and orifices of the coronaries are noted. The degree of peripheral commissural fusion and nodular excrescences on the cusps composed of myxomatous tissue and the thickened part of the cusps are identified.

Clip 4: The fused commissures are carefully divided with a knife, ensuring that the leaflets are well supported and not liable to prolapse. The false raphe, if present, does not provide any lateral support for the cusp, and it should not be incised. Obstructive myxomatous and fibrous nodules on the cusps are removed. This implies careful and meticulous thinning/shaving of the cusps with a knife

Clip 5: The opening of the valve, the mobility of the cusps and the geometry is assessed. Correctly performed “shaving” greatly improves the mobility of the cusps and the effective orifice area of the aortic valve. The effective orifice area is checked by “olive” (an olive-shaped probe is inserted into the orifice), and the commissurotomy is extended, if necessary. Even a short commissurotomy incision could result in adequate opening of the outflow orifice, because the flow is a function of the fourth power of the radius.

Clip 6: The aortotomy is closed with a running suture. After rewarming, the patient is weaned from the cardiopulmonary bypass. Transesophageal echocardiographic assessment of the left ventricular function, aortic valve function, and flow characteristic in the left ventricular outflow tract should be carried out routinely. The ductus arteriosus should always be ligated if the patient is stable. If cardiac output is not adequate, even on aggressive inotropic support, the duct can be left opened and maintained patent on prostaglandins to provide additional systemic perfusion from the right ventricle.


Clip 1: Preoperative echocardiogram.

Clip 2: Postoperative echocardiogram.

Clip 1: Preoperative findings.

Clip 2: Opening of the aorta.

Clip 3: Resection of the subaortic membrane.

Clip 4: Closure of the aneurysm of the sinus Valsalva.

Clip 5: Assessment of the anatomy and function of the valve.

Clip 6: Augmentation of left and right coronary cusps with autologous pericardium.

Clip 7: Postoperative echocardiogram.


Clip 1: Preoperative findings.

Clip 2: Tricuspidalization of the valve. The left coronary cusp and a new commissural post is fashioned. The noncoronary cusp is used as a reference point to adjust the length of the left cusp with the aim of achieving a symmetric arrangement.

Clip 3: The right coronary cusp is created from a patch of autologous pericardium. The length of the half-moon–shaped patch should be 15% greater than the diameter of the aorta. The 15% additional length accounts for a reduction in the pericardial cusp free-edge width that results from a purse-string effect with a running polypropylene suture. The height is governed by the extent of augmentation and anticipated height of the newly created commissure.

Clip 4: Reinforcement of the commissures.


Clip 1: Closure of the abscess formation and reconstruction of the noncoronary cusp.

Clip 1: Preoperative findings.

Clip 2: The right and left coronary buttons are formed and dissected for maximal mobilization.

Clip 3: The aortic cusps and sinus wall are removed, leaving an approximately 3–5 mm cuff of the aortic wall in place.

Clip 4: The pulmonary autograft is harvested. The main pulmonary artery has been divided proximal to the branches, and the proximal vessel with the valve is harvested from the right ventricle. A circumferential muscle bar is taken with the graft. After harvesting the pulmonary valve, cardioplegia is delivered, and any bleeding points from the area of previous dissection are controlled by either diathermy or are over-sewn with a shallow suture.

Clip 5: In adolescents, in the case of a geometric mismatch of at least 3 mm in favor of the aortic annulus, the commissures on either side of the noncoronary sinus are plicated down with pledget-supported sutures to ensure the proper autograft fit and function. The pulmonary autograft is then sutured to the left ventricular outflow tract opening using a continuous suture.

Clip 6: Reinforcement of the seated autograft is performed.

Clip 7: The left coronary artery is reimplanted into the neoaortic root.

Clip 8: The neoaortic reconstruction is completed by proximal anastomosis with the ascending aorta. Before the anastomosis is completed, the right anterior commissure is marked on the outside of the autograft to avoid inadvertent injury to the valve leaflet during the implantation of the right coronary artery.

Clip 9: The right coronary artery is reimplanted into the neoaortic root.

Clip 10: A homograft or bovine jugular vein conduit is used for reconstruction of the right ventricular outflow tract.

Clip 11: A pulmonary valve homograft is anastomosed with the right ventricular outflow tract.

Clip 12: After de-airing, the aortic clamp is released and the patient is weaned from bypass. An echocardiogram should be routinely performed after weaning the patient from bypass.


Clip 1: Preoperative echocardiogram.

Clip 2: Opening of the aorta and assessment of the underlying anatomy.

Clip 3: Resection of the membrane.

Clip 4: Resection of the secondary chordae of the mitral valve and myectomy.

Clip 5: Postoperative echocardiogram.


Clip 1: External anatomy of the heart.

Clip 2: In children, a technique of complete root replacement with anterior aortoventriculoplasty is used. After aortic cross-clamping, the aorta is partially transected, and the feasibility of valve repair is assessed. The main pulmonary artery is transected just proximal to the bifurcation of the PA.

Clip 3: After complete transection of the aorta, the right and left coronary buttons are formed and dissected for maximal mobilization.

Clip 4: The aortic cusps and sinus wall are then removed, leaving an approximately 3- to 5-mm cuff of the aortic wall in place.

Clip 5: The pulmonary autograft is harvested, along with an extension of the infundibular free-wall muscle, which is attached to it. This extra tissue is used for patching the ventriculoplasty incision.

Clip 6: After harvesting the pulmonary valve, cardioplegia is delivered, and any bleeding points from the area of previous dissection are controlled, either by diathermy or by over-sewing with a shallow suture. When the operation is finished, it is very difficult to control any potential source of bleeding from this area.

Clip 7: The aortic annulus is enlarged by incising the interventricular septum in the left-right commissure.

Clip 8: Resection of any endocardial fibroelastosis or ventricular myectomy is performed, if necessary. The goal is to remove any fibrous tissue that could obstruct the left ventricular outflow tract and limit the movement of the left ventricular cavity.

Clip 9: The pulmonary autograft is implanted in the left ventricular outflow tract using a running-suture technique. Natural alignment of autograft is preferable. The left semilunar cusp of pulmonary autograft should occupy the area of the previous left coronary cusp. The anterior semilunar cusp of pulmonary valve (autograft) is therefore orientated anteriorly, and the anterior lip of the retained infundibular free wall is used to patch the triangular area of incised interventricular septum.

Clip 10: It is important to reinforce the patching of the ventriculoplasty incision with pledgeted interrupted mattress sutures to minimize the risk of bleeding or aneurysm formation.

Clip 11: Reimplantation of the left coronary artery into the neoaortic root is performed first. Afterwards, the neoaortic reconstruction is completed by distal anastomosis with the ascending aorta using a continuous suture, followed by reimplantation of the right coronary artery into the neoaortic root.

Clip 12: The right ventricular outflow tract is reconstructed with the homograft or bovine jugular vein conduit.

Clip 13: An echocardiogram should be routinely performed after the patient has been weaned from bypass.


Clip 1: Preoperative angiography.

Clip 2: External morphology of the heart.

Clip 3: Transection of the aorta and vertical incision of all three sinuses.

Clip 4: Three teardrop-shaped patches are sutured into each of the sinuses of Valsalva.

Clip 5: Patch enlargement of the central pulmonary artery.

Clip 6: Reconstruction of the ascending aorta.

Clip 7: Postoperative findings.

Clip 8: Postoperative echocardiogram.


Clip 1: The aorta is transected at the narrowest point above the commissures. Any thickened area on the distal aorta is excised. Vertical incisions are made, similar to those in a three-patch technique, into the sinuses of Valsalva that are affected. Care is taken to avoid the coronary ostia; thus, the incisions are made off-center of the sinuses. Complementary vertical incisions are made in the distal aorta, out of phase with the proximal incisions. This allows interdigitation of the proximal and distal flaps when the aorta is reanastamosed. A zigzag anastomosis enlarges the aortic root.

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Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Viktor Hraška
    • 1
  • Peter Murín
    • 1
  1. 1.Department of Cardiac SurgeryGerman Pediatric Heart Centre, Sankt AugustinSankt AugustinGermany

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