Aortic valve repair for insufficiency in older children offers unpredictable durability that may not be advantageous over a primary Ross operation

Abstract

OBJECTIVES:To evaluate the durability of aortic valve (AoV) repair relative to other strategies for children with significant aortic insufficiency (AI). METHODS:From 2001 to 2012, 90 children with greater than or equal to moderate AI underwent surgery. Resulting procedures were classified according to final operative outcome: AoV repair (repair; n = 46, 51%), Ross procedure (Ross; n = 21, 23%) or replacement with mechanical or tissue prosthesis [aortic valve replacement (AVR); n = 23, 26%]. Repeated measures (n = 1081 echocardiograms) mixedmodel analysis and parametric multiphase risk-adjusted hazard analysis were used to evaluate haemodynamic parameters and durability of operations.RESULTS: Mean age at operation was similar for repair and Ross groups, but slightly higher for the AVR group (10.6, 11 and 13.2, respectively; P = 0.04). Baseline annular dimensions were similar among groups. Of 46 repairs, 85% involved pericardial leaflet extensions (commonly with leaflet shaving and/or commisuroplasty). The remaining repairs were commissuroplasties. On multivariable analysis, repair was associated with increased early ( 1-2 years) AI and increased outflow tract peak pressure gradients relative to Ross and AVR procedures. On univariate analysis, repairs tended to have a larger annulus size compared with Ross or AVR; however, this was not significant on multivariable analysis. There were 25 reinterventions (surgical reoperation = 16; transcatheter intervention = 9) for 22 children. Freedom from surgical reoperation was 64, 100 and 51% at 6 years for repairs, Ross and AVR, respectively (P = 0.05); however, three of five reoperations after AVR were for failed bioprosthetic devices. The freedom from reintervention was not significantly influenced by the type of AoV operation (P = 0.43).CONCLUSIONS: Durability of aortic valve repair for children is limited by recurrence of AI and/or stenosis, often within the first few years. After repair, reoperation should be anticipated within 7 years.

Aortic valve surgery: management and outcomes in the paediatric population

“…This is an exceptional imaging tool which yields high-quality images and allows essential preoperative planning for transcatheter aortic valve replacement (TAVR) [23]. Although TAVR is not routinely used in the paediatric population, a study conducted in 2019 found this method of valve replacement to be a reasonable alternative to surgical aortic valve replacement in certain paediatric patients with suboptimal predicted surgical outcomes [24]. Furthermore, CCT may aid in characterising aortopathy in patients with inconclusive echocardiography findings [16].…”

“…CMR and 4D flow MRI provide robust data on patientspecific aortic haemodynamics [24][25][26]. This helps to predict risk of disease progression, particularly in BAV20.…”

“…Surgical repair of the paediatric aortic valve is an everdeveloping area of research. The current gold-standard surgical procedure used in congenital aortic stenosis is the Ross procedure [55]. Although this procedure is well established, it is worth noting that there are some limitations associated, such as the need for expertise, extensive training and lifelong monitoring of patients [55].…”

Long-term outcomes of aortic valve repair in children with congenital heart disease and their predictors

“…В результате пациенты, у которых не применяли аугментацию створки АК, демонстрировали лучшую свободу от реопераций. В поддержку этой гипотезы говорят также результаты Wilder TS, et al, которые получили практически 50% реопераций у детей старше 1 года, которым применялась данная методика РеАК со средним периодом времени до повторного вмеша-тельства 4,4 года, что перекликается с нашими данными [14].…”

“…Дефицитная ткань часто имеет предпосылку к выполнению таких методик, как комиссуротомия в сочетании со швом Trusler, рафе "шейвинг", аугментацией створок. Согласно данным Wilder TS, et al, помимо преимущественного применения такой методики, как аугментация створок, некоторым пациентам была выполнена комиссуротомия в комбинации со швом Trusler [14]. Однако пликация свободного края створок или триангулярная резекция не была применена, что свидетельствует об исходно плохом качестве, количественном дефиците створок, в результате чего получен субоптимальный результат, который перекликается с нашими данными.…”