How to Use the RAA Valve for the Ross-Konno Operation in Children

The Ross and Ross-Konno procedures remain the optimal surgical options for aortic valve replacement in small children. However, a major drawback is the eventual need for reintervention due to the degeneration of the homograft in the pulmonary position. To address this, the authors have developed a technique that incorporates the right atrial appendage (RAA) valve—previously described for use in tetralogy of Fallot (1)—into these procedures. Based on the promising results in 247 tetralogy of Fallot patients with the RAA valve, this modification may delay or even eliminate the need for reintervention. 
 
In older children and adults, the surgeons successfully used and previously demonstrated the T-RAA valve, wherein the RAA valve is placed inside a Gore-Tex tube to create a valved conduit for the right ventricle-to-pulmonary artery (RV-PA) connection after removing the pulmonic valve as the autograft (2). However, this approach is not feasible in small children due to the lack of growth potential. 
 
This video demonstrates the novel technique developed by the authors for incorporating the RAA valve as a homograft alternative in small children. A key innovation was designing the RV-PA connection with a combination of native living tissue to allow for growth, similar to the approach used by the authors in tetralogy of Fallot repairs.  

The anterolateral portion of the ascending aorta was removed as a half cylinder and utilized for the floor of the RV-PA pathway.  
 
The RAA valve was harvested and implanted into the right ventricular outflow tract (RVOT), with the aortic wall serving as the posterior wall and a bovine pericardial patch as the anterior wall of the new pulmonary artery.  
 
The aortic defect was reconstructed with a bovine pericardial patch, which preserved aortic growth potential. The remainder of the operation followed the standard Ross or Ross-Konno technique. 
 
To date, the authors have performed this procedure in three patients aged 2, 5, and 8 years. Short-term outcomes have been excellent, with no stenosis or regurgitation observed in either the aortic autograft or the pulmonary RAA valve. However, larger patient cohorts and longer follow-up are needed to draw definitive conclusions. It should be noted that this technique can also be used in other categories of congenital anomalies, such as pulmonary atresia, where the RAA valve is desired but there is no main pulmonary artery available to form the posterior wall of the RV-PA connection. 

References

1. Amirghofran AA. How to Make a Valve for the RVOT from the Right Atrial Appendage. Ctsnetorg. Published online October 19, 2022. doi:https://doi.org/10.25373/ctsnet.21354825.v1
2. Amirghofran AA. Ross Procedure Using the Right Atrial Appendage Valve Instead of a Homograft: An All-Native Valve Approach. Ctsnetorg. Published online April 23, 2025. doi:https://doi.org/10.25373/ctsnet.28840751

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