الفهرس 
INTRODUCTION & AIM OF WORK
LVOT obstructionOnly 14 pages are availabe for public view
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Abstract
In summary, this study included 58 patients (46 children and 12 adult) suffering from left ventricular outflow tract obstruction operated upon at a mean age of 14.51 ±1.82 years (range, 2.4 year - 65 years).
Those patients were classified according to the level of left ventricular outflow tract obstruction into three groups:
Group (I): included 44 patients with discrete subaortic stenosis. Divided to:
Group (I-A): Resection of the subaortic membrane with Morrow myectomy. Include 31 patients.
Group (I-B): Resection of the subaortic membrane without Morrow myectomy. Include 13 patients.
Group (II): included 12 patients with valvular aortic stenosis.
Group (III): included 2 patients with supravalvular aortic stenosis.
Within the 44 cases of group I (discrete subaortic membrane), the mean age of all of the patients was 9.264 ± 0.792 years (range, 2.4 – 28 years) .In group I-A, (Resection of the subaortic membrane with Morrow myectomy), Included 31 patients. The mean age was 7.66 ± 0.759 years (range, 2.4 – 20 years). While; group I-B, (Resection of the subaortic membrane without Morrow myectomy Included 13 patients). There was a statistically significant difference (p=0.001), between the mean ages of group I-A and I-B, with patients of group I-A being operated early in life than patients of group I-B.. No early or late deaths occur. we encountered a recurrence of LVOT gradient (more than 30 mmHg), in one patient of group I-A who developed gradient 33 mmHg at a follow up period of 6 months and 3 patients of group I-B, developed recurrent gradients of 35, 33, and 31 mmHg at a follow up period of 42.70, 47.70, and 52.97 months, respectively.
An aggressive surgical approach to discrete subaortic stenosis produces excellent relief of obstruction and frees the valve leaflets, significantly reducing associated AR at early and mid-term follow-up with low morbidity for primary operation. Severity of aortic regurge, improved in all patients of group I-A aortic regure grade II/IV not improved in 5 patients in group I-B.
Group II patients had the oldest age of operative interference in comparison to the other 2 groups. Include 12 patients with valvular aortic stenosis. The mean age of operative interference was 33.83 ± 5.5 years. In our thesis 8, patients had aortic valve replacement without root enlargement 4 in supra-annular position and 4 in intra-annular position 3 of them had minimal mismatch. The mean follow-up of all of patients in this group was 4.60 ± 0.67 months (range, 3 – 8 months).
One patient had Nicks’ posterior enlargement and the annulus was enlarged from 19 to 21 mm and 19 mm Reagent St Jude prosthesis was inserted in supra-annular position. Therefore, while with the Nick’s procedure is less traumatic but allows for only a few millimeters enlargement, So. It is generally limited to a one-size larger prosthesis; If need Nicks’ method, the inserted prosthetic valve may be placed in an oblique fashion by lifting one edge at the enlarged NCC area.44
One patient had Manouguian posterior enlargement and the annulus was enlarged from 15 mm to 19 mm and Carbomedics prosthesis is inserted in supra-annular position, and the patient had mitral valve replacement St Jude 25 mm for mitral regurge III/IV. With the Manouguian incision one can insert a two-size larger prosthetic valve.56
One patient had Konno–Rastan procedure. He had multi-level LVOTO .He had tunnel subaortic stenosis and hypoplastic aortic annulus .so, anterior enlargement is done and the annulus was enlarged from 10 to 15 mm. So, Choice among the 3 common techniques of root enlargement can be dictated by individual surgeon experience, as well as complexity inherent to the procedure. The Konno–Rastan procedure offers the greatest degree of root enlargement. It is a complex procedure, however, requiring creation of a ventricular septal defect and right ventriculotomy, with double-patch closure of both. This risks damage to the septal arteries, as well as the conduction system, and places the patient at risk of ventricular septal perforation.59 in our case transient heart block for 3 hours occur.
One patient has Ross operation (pulmonary autograft) and homograft was applied on pulmonary site. But the patient died immediate postoperative due to due to persistent low cardiac output and haemodynamic instability. It was the only early mortality due to uncontrolled bleeding and haemodynamic instability. No case has reoperation or late mortality.
The 2 patients of group III had been operated upon at a mean age of 14.00 ± 3.00 years. Follow up was 3 months for both cases. Age of them was 11 and 17 years .Both had pantaloon bifurcated patch dilatation with no residual high gradient, no aortic regurge, no early or late postoperative mortality.