Changes in mitral and aortic valve diameters. A, before Commando-Ross-Konno procedure. B, After Commando-Ross-Konno procedure.
Central message.
Commando-Ross-Konno is a good option for pediatric patients with left ventricular inflow and outflow tract obstruction with small aortic and mitral annuli and limited replacement options.
Since first described in 1997, the Commando procedure, involving the division and reconstruction of the intervalvular fibrous body (IFB) between the aortic valve and mitral valve (MV), was reserved mainly for cases of infective endocarditis with destruction of the IFB.1 Its use in pediatric patients with a small MV annulus requiring MV replacement has only been described in 5 patients with excellent outcomes.1 However, some patients also have left ventricular outflow tract obstruction (LVOTO) requiring enlargement and replacement of the aortic valve. We describe a combined Commando-Ross-Konno procedure as a novel solution. Institutional review board approval was not required and individual consent was waived.
Clinical Summary
The patient was born with a partial atrioventricular septal defect (AVSD) with a large primum atrial septal defect (ASD), a small left atrioventricular valve (LAVV), and mild aortic valve and aortic arch hypoplasia. At age 2 months, she underwent partial AVSD repair with closure of the primum ASD, closure of the LAVV cleft, and repair of her right atrioventricular valve (RAVV) at an outside hospital.
She was referred at age 17 months with severe LAVV/RAVV regurgitation, pulmonary hypertension, mild LVOTO, and mild aortic valve hypoplasia and underwent a surgical Melody (Medtronic) valve implantation (dilated to 18 mm) in the LAVV position, RAVV repair, LVOTO resection, and ascending aorta patch enlargement. At age 3.5 years, due to severe Melody valve stenosis, severe RAVV regurgitation, moderate LVOTO, and pulmonary hypertension, she underwent LAVV replacement with a 19-mm mechanical St Jude Medical (Abbott) valve, RAVV repair, and LVOT myectomy. During the postoperative period, she experienced complete heart block and required a permanent pacemaker implantation. At age 5 years, due to severe LVOTO (peak gradient 103 mm Hg) and mild-moderate mechanical MV stenosis (peak/mean gradient 24/9 mm Hg), she underwent a Commando procedure with a Ross-Konno procedure (details below). Intraoperative echocardiogram showed good biventricular function, an unobstructed LVOT with a well-functioning pulmonary autograft, and a well-seated unobstructed mechanical MV. She was extubated in the operating room and discharged on postoperative day 5. Nine months postoperatively, she remains well with her most recent echocardiogram demonstrating an unobstructed LV inflow and outflow.
Surgical Technique
Following aortic crossclamping (ACC), the aorta was opened just above the sinotubular junction, and the coronary buttons were harvested. The native aortic valve was excised and the pulmonary root harvested with a V-shaped muscle cuff (internal diameter of 19-20 mm). The mechanical MV was explanted through a superior transseptal approach. A Commando procedure was performed using a bovine pericardial patch to recreate the IFB. A 21-mm St Jude Medical MV was implanted with the posterior two-thirds anchored to the native annulus and the anterior one-third to the bovine patch, part of which was used to close the interatrial septum. A Konno incision was performed slightly leftward of the left-right commissure followed by extensive myectomy.
The left coronary artery was reimplanted and the right ventricular outflow tract reconstructed using a 23-mm pulmonary homograft. The aortic root was completed after reimplanting the right coronary artery. Cardiopulmonary bypass and ACC times were 225 minutes and 192 minutes, respectively. By combining the Commando with a Konno incision, the aortic and mitral annuli were significantly enlarged (See Table 1, Video 1, Figure 1).2
Table 1.
Preoperative versus postoperative aortic and mitral valve dimensions
| Variable | Preoperative (cm) | Preoperative z score∗ | Postoperative (cm) | Postoperative z score∗ |
|---|---|---|---|---|
| Mitral valve | 2 | 0.3 | 2.8 | 3.8 |
| Aortic valve | 0.75 | −7.5 | 1.7 | 2.9 |
SickKids z score was used for the calculation.
Figure 1.
Overview of the Commando-Ross-Konno procedure. A, The aorta was opened at the sinotubular junction and the coronary buttons and pulmonary autograft were harvested. The left atrium was opened through a transseptal approach, mechanical mitral valve (MV) was explanted, intervalvular fibrous body was divided, and pledgeted sutures were placed in the posterior MV annulus. B, New mechanical MV was implanted, posteriorly anchored to the native MV annulus and anteriorly to a bovine pericardium. The left atrium was closed with remaining patch and a Konno incision was performed. C, and D, Final result after implanting the pulmonary autograft, the coronary arteries, and the homograft in the pulmonary position.
Discussion
Children with combined LV inflow obstruction and LVOTO pose a significant surgical challenge due to small annular dimensions and limited valve options. Both the Commando procedure and the Konno incision facilitate implanting larger prostheses, in this case a 21-mm mechanical MV and a 19- to 20-mm pulmonary autograft, with a goal to delay future interventions. Although the Ross-Konno adds surgical complexity—potentially transforming a 2-valve into a 3-valve pathology—it may offer a more durable long-term solution. Although cardiopulmonary bypass and ACC times were longer than for Commando procedures with mechanical aortic valve replacements (225 vs 199 minutes and 192 vs 136 minutes, respectively3), recovery was unremarkable supporting the feasibility of this complex combined approach. One could argue the usefulness of a Ross procedure over a mechanical aortic valve in a patient who already required anticoagulation therapy for a mechanical mitral valve. Other groups have demonstrated that the Ross procedure offers advantages over a mechanical aortic valve replacement, particularly in patients with smaller valve sizes (16-17 mm).4 In our case, after performing the Konno incision, the native aortic valve annulus increased to approximately 17 mm, which likely would have not accommodated a substantially larger mechanical valve.
There are some important technical aspects. The transseptal superior approach provides not only excellent MV exposure but also the access to IFB. There is a risk of leaflet distortion due to the use of a non-native bovine patch for aortic annulus reconstruction along the noncoronary sinus and due to the extensive Konno incision.. Therefore, particular attention should be made to ensure minimal geometrical distortion of the autograft leaflets during the autograft implantation. Oversizing the mechanical MV may result in LVOTO despite the Konno incision and therefore sizing of the mechanical MV should be carefully done, taking the subsequent LVOT size after Konno enlargement into consideration.
Conclusions
The combination of Commando and Ross-Konno procedures is a feasible and promising strategy in children with small aortic and mitral annuli and limited replacement options. Although technically demanding, recovery and early outcomes are excellent with the hope of a longer-term solution.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Supplementary Data
Commando with Ross-Konno procedure. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00371-2/fulltext.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Commando with Ross-Konno procedure. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00371-2/fulltext.