Konno aortic valve replacement in adults: Enabling larger prosthetic valve implantation and adequate aortic root enlargement for coronary clearance.

OBJECTIVE

Surgical aortic valve replacement in patients with severe aortic stenosis and small annuli remains challenging owing to prosthesis-patient mismatch and the limited feasibility of subsequent valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). The Konno procedure enables annular and left ventricular outflow tract (LVOT) enlargement; however, outcomes in adults remain insufficiently defined.

METHODS

Between January 2023 and October 2025, 193 patients underwent surgical aortic valve replacement at our institution, of whom 19 (10%) received the Konno procedure for annulus diameter ≤19 mm, high likelihood of prosthesis-patient mismatch, or anticipated ViV-TAVR with estimated high risk of coronary obstruction. Operative results, echocardiographic and electrocardiographic parameters, and computed tomography measurements of the aortic root were assessed before and after surgery.

RESULTS

Patients were aged 59 ± 19 years and 84% were women. Bioprostheses were implanted in 12 patients (63%) and mechanical valves in seven (37%), with enlargement permitting prosthesis implantation 2 to 3 sizes larger. Septal myectomy was performed in 6 patients. No in-hospital mortality occurred. Computed tomography demonstrated enlargement of the sinus of Valsalva (+7.0 mm) and sinotubular junction (+6.9 mm), consistent with ViV-TAVR feasibility. Echocardiography confirmed relief of LVOT obstruction; however, right ventricular diameter tended to increase, tricuspid annular plane systolic excursion declined, and QRS duration increased from 90 to 114 milliseconds, indicating intraventricular conduction delay.

CONCLUSIONS

Konno aortic valve replacement facilitates implantation of larger prostheses, relieves LVOT obstruction, and optimizes root anatomy for future ViV-TAVR. Conduction disturbances and right ventricular functional decline warrant long-term surveillance.