Aortic valve bypass with a valved apicoaortic conduit is one of the options available to relieve left ventricular outflow tract (LVOT) obstruction. The concept of creating a double-outlet left ventricle dates back to early work by Carrell in the early 1900s. Subsequently, largely experimental attempts to create such a conduit were fraught with limitations relating to hemorrhagic complications at the myocardial anastomosis and degeneration of the homograft valves. Refinements were introduced in the 1950s and 1970s, and better outcomes were achieved with the use of specialized prostheses. Dr. Cooley, the senior author of this chapter, and his colleagues built on their vast experimental work involving pumping prosthesis between the LV apex and the abdominal aorta and saw a clinical application of this technique through a modified nonpumping prosthetic LV apical–abdominal valved composite conduit.

Cooley et al. emphasized the necessity of rigid thromboresistant LVOT prostheses and described the use of alternative techniques with or without cardiopulmonary bypass. Their distal anastomosis was most commonly performed to the supraceliac abdominal aorta; other sites included the infrarenal aorta, ascending aorta, lesser curvature of the aortic arch, and descending aorta.

The apical-to–descending aortic conduit has gained traction in recent years through work by Brown and Gammie. In addition, cardiac surgeons have become more familiar with the ventricular apex because of the increased use of ventricular assist devices and the introduction of transapical transcatheter aortic valve replacement (TAVR) technologies. These trends have helped revive the use of the apicoaortic bypass option in select patients with LVOT obstruction.

Steps taken in the work-up and preparation of the patient for apicoaortic conduits are similar to those taken in SAVR. Importantly, echocardiography is performed to confirm the LVOT obstruction and to rule out significant aortic regurgitation. Coronary angiography is performed to rule out hemodynamically significant coronary artery disease. Pulmonary function tests are particularly important in patients with a history of pulmonary disease to ensure that they can tolerate thoracotomy.

A computed tomography scan of the chest, abdomen, and pelvis with contrast is important in defining the chest anatomy, identifying a suitable aortic anastomosis site, and determining whether femoral access is an option for cardiopulmonary bypass.

As noted earlier, there are a variety of approaches for apicoaortic conduit surgery, the choice of which is dictated by the site of the aortic anastomosis. For the purposes of this chapter, we will focus primarily on the procedure most commonly performed today, namely a left thoracotomy approach for an apical-to–descending aortic bypass.