Management of complex left ventricular outflow tract obstruction with pulmonary autografts

The surgical relief of complex multilevel left ventricular outflow tract (LVOT) obstruction remains a challenging surgical problem. We present a new operation which combines the concepts of aortoventriculoplasty, extended aortic root replacement, and the use of a pulmonary autograft. Sixteen patients underwent this operation: 11 patients after previous attempts to relieve diffuse subvavalvular stenosis and 5 patients who presented excessive gradients over a previous aortic valve prosthesis. All patients except one survived the operation. One patient developed massive right ventricular infarction and underwent transplantation after 5 days. Another patient developed complete heart block and transient tricuspid regurgiation after a septal infarction. One patient remained in congestive heart failure and died suddenly after 17 months. All other patients are in NYHA class I after a mean follow-up of 23 +/- 12 months. One patient developed progressive dilatation of the neo-aortic root and underwent reoperation after 4 years. All other patients showed laminar flow in the LVOT and excellent function of the autograft and homograft valve at follow-up. This operation offers a more durable or even a definitive solution in the management of these complex left ventricular outflow tract obstructions.