Alfred Kocher technique for prevention of patient–prosthesis mismatch in paediatric patients

Aortic valve replacement requires special considerations in paediatric patients, who are not yet fully grown. The Ross procedure remains the gold standard in paediatric patients as it offers growth potential. If the Ross procedure is not feasible, or the size of the aortic annulus precludes placement of an adult-sized mechanical prosthesis, the problem of patient-prosthesis mismatch and subsequent aortic valve reinterventions arises. The standardized option for this patient cohort is the Konno incision and patch ventriculoplasty in combination with an adult-sized mechanical prosthesis, which carries substantial procedural complexity and risk. This video tutorial demonstrates posterior aortic root enlargement using the Alfred Kocher technique in a 7-year-old female with a functionally unicuspid aortic valve and a bicuspid pulmonary valve. The bicuspid pulmonary valve was an unplanned intraoperative finding, making the patient ineligible for a durable autograft transplantation. The technique involves an inverted T-shaped incision in the centre of the non-coronary sinus, and reconstruction with a barrel-shaped patch tailored from a 28 mm Valsalva prosthesis to augment the non-coronary sinus in an anatomical fashion, allowing upsizing by 5 mm in annular diameter. This technique enabled implantation of a 21 mm size mechanical prosthesis (diameter = 24 mm) upsized from a 19 mm annulus.