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Left ventricular outflow tract obstruction

Types of operations

There are a number of options available to enlarge an obstructed left ventricular outflow tract.

Figure 17-1, A This illustration shows the aortic root and the various points at which the aortic annulus can be divided to open the left ventricular outflow tract. The options include an anterior incision medial to the orifice of the right coronary artery (Konno-Rastan operation), an anterior incision through the medial commissure of the aortic valve (Vouhe operation), and posterior enlargement incisions. An incision into the posterior commissure and the interleaflet triangle below it has been described by Manougian and Nunez; an incision at the low midpoint in the noncoronary sinus is attributed to Nicks. B The Konno-Rastan operation is commonly referred to as an aortoventriculoplasty because the incision extends from the aorta medially across the aortic annulus into the right ventricular outflow tract and the ventricular septum. C The Vouhe operation is also an aortoventriculoplasty. The aortic incision is through the commissure between the left and right coronary cusps of the aortic valve. Thus, the incision into the right ventricle is made in the outlet portion and into the infundibular septum. This offers the option of preserving the aortic valve if it is normal or repairable. D In the Manougian operation, an incision is extended from the aorta through the posterior commissure between the left and noncoronary cusps of the aortic valve, into the interleaflet triangle, and across the mitral annulus about 1 cm into the middle of the anterior leaflet of the mitral valve. The left atrium is also opened. E In the Nunez operation, described 4 years after the Manougian operation, an incision is also made through the posterior commissure into the interleaflet triangle, but it stops short of entering the mitral valve and the left atrium. F The Nicks operation extends an aortic incision across the aortic valve annulus at the midpoint of the noncoronary sinus into the anterior aspect of the anterior leaflet of the mitral valve. The left atrium is also opened.

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