What is the Difference Between the Konno, Ross and Rastelli Surgical Procedures
To begin, there is really no “one size fits all” surgical procedure, just as there is no “one size fits all” congenital heart defect. These procedures and defects are highly individualistic and depend on the range and severity of the problem.
First, some terminology.
Autograft: The transplantation of tissue from one part of the body to another part of the body (genetically identical tissue).
Homograft: The transplantation of tissue between similar species e.g. human to human.
Xenograft: The transplantation of tissue between different species e.g. pig, horse and cow valves are a good example.
Fibrous: hard, cartilage like structures in the body such as ligaments and tendons (connective tissue).
Fibro-muscular: That part of fibrous tissue that connects itself to muscle tissue.
Infundibulum (Conus): The elongated, tubular structure that is the right ventricular outflow tract (RVOT).
The four valves of the heart, mitral, aortic, pulmonic and tricuspid (MV, AOV, MV and PV), is a contiguous apparatus made up of fibrous tissue that also includes the attachments of the atrial and ventricular septums, and is connected to the muscular portion of the heart via fibro-muscular tissue. This apparatus is also known as the “cardiac skeleton”. The MV and TV lie on the same plane with each other, while the AOV and the PV are perpendicular to each other thanks to the infundibulum (or conus).
Remember that heart defects (hence the surgeries that repair them) cannot be easily standardized or compartmentalized since numerous heart defects can occur in conjunction with each other. Below, I will outline the basics of these typical surgeries.
The Konno and Ross procedures are primarily used to repair aortic outflow lesions that may be supravalvular, valvular, or subvalvular (or any combination therein), while the Rastelli procedure is used to reconstruct severe pulmonary outflow obstructions that may or may not include lesions such as atrial septal defects (ASD), ventricular septal defects (VSD), patent ductus arteriosis (PDA) and the pulmonary artery (PA).
Konno repair: This is an aortic root replacement procedure where there is severe aortic valvular obstruction and hypoplasia of the aortic root with (typically) subvalvular obstruction. An aortic or pulmonary homograft replaces the aortic root and valve, and may involve remodeling of the left ventricular outflow tract (LVOT) and the ascending aorta. In some instances, a mechanical prosthetic valve may be used in lieu of a homograft.
Ross repair: This procedure differs from the Konno procedure in that the patient’s native pulmonic root and valve are used to replace the aortic root and valve (autograft), and the pulmonic valve and root are replaced with a homograft. The advantage of using the Ross procedure is that native tissue enables the aortic repair to grow as the patient grows. Unfortunately, the pulmonary homograft may have to be replaced over time.
Why use the Ross procedure in lieu of the Konno procedure? Remember that the left side of the heart has much higher pressures and stress on the aortic apparatus as opposed to the low pressure environment of the right side of the heart. Using native tissue significantly reduces the possibility of tissue rejection and hence stroke.
Rastelli repair: This is a complex procedure that addresses significant pulmonary artery obstructions such as pulmonary atresia (absence of a pulmonic valve), collateralized pulmonary arteries (MAPCA’s or major aorticopulmonary collateral arteries) and often includes the repair of a VSD, ASD and PDA. This procedure can be done in stages, and begins with a Blalock-Taussig shunt (re-routing of blood flow from the brachiocephalic artery to the right pulmonary artery) which is used to re-establish pulmonary blood flow until the neonate can tolerate more complicated procedures.
This procedure may involve the use of a valved homograft to replace the PV, reconstruction of the pulmonary artery and the origins of its branches and the repair of any other defects such as an ASD, VSD and a PDA. The purpose of this repair is to re-establish normalized pulmonary arterial blood flow between the right ventricle and the pulmonary arteries.
Thank you for your time and patience
Ken Heiden RDCS, RVT