Surgical Valvuloplasty Versus Balloon Dilation for Congenital Aortic Stenosis in Pediatric Patients

Abstract

<jats:sec><jats:title>Background:</jats:title><jats:p> For children with congenital aortic stenosis (AS) who are candidates for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter balloon aortic dilation (BAD). We aimed to evaluate the longer term outcomes of SAV versus BAD at our institution. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> We retrospectively reviewed the outcomes of 2 months to 18 years old patients who underwent SAV or BAD at our institution between January 1990 and July 2018. Baseline and follow-up characteristics were assessed by echocardiography. Long-term survival, freedom from reintervention, freedom from aortic valve replacement (AVR), and aortic regurgitation were evaluated. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> A total of 212 patients met inclusion criteria (SAV = 123; BAD = 89). Age, sex, aortic insufficiency (AI), and aortic valve gradient were similar between the groups. At 10 years, 27.9% (19/68) of SAV patients and 58.3% (28/48) of BAD patients had moderate or worse AI ( P = .001), and reintervention occurred in 39.2% (29/74) of SAV patients and 78.6% (44/56) of BAD patients ( P &lt; .001). Kaplan-Meier analysis revealed overall survival was 96.8% (119/123) for SAV and 95.5% (85/89) for SAV ( P = .87). At 10 years, 35% (23/66) of SAV patients and 54% (23/43) of BAD patients underwent AVR ( P = .213). </jats:p></jats:sec><jats:sec><jats:title>Conclusions:</jats:title><jats:p> Surgical aortic valvuloplasty demonstrated greater gradient reduction, less postoperative and long-term AI, and a lower reintervention rate at 10 years than BAD. There was no difference in survival or AVR reintervention rate. Surgical aortic valvuloplasty is a durable and efficacious intervention and should continue to be considered a favorable choice for palliation of valvular AS. </jats:p></jats:sec>

Commentary: Surgical aortic valve repair as the primary option for children with congenital aortic stenosis

“…Although some initially championed open valvuloplasty for patients beyond the newborn period, 6 they and others have extended the strategy to include neonates with 7 or without significant left ventricular dysfunction. 8,9 In this study, the median age at surgery was just 0.4 years, with neonates accounting for one-quarter of patients. 1 Survival for neonates was outstanding, with no hospital deaths and just 1 late noncardiac death.…”

“…While some recommend judicious tricuspidization as needed, 10 others caution against it, especially in infants and young children. 6,8,9 It can be a difficult dilemma, and one may have to weigh the competing risks of a suboptimal result due to residual stenosis of an intact raphe versus the risk of reoperation due to patch support of the divided raphe. Still, some patch techniques may be less egregious than others.…”

Aortic valve surgery: management and outcomes in the paediatric population

“…Brain MRI studies have revealed a pattern of delayed brain maturation and evidence of chronic diffuse white matter injury in foetuses with AVS with secondary HLHS. In addition, abnormal neurologic exams and microcephaly have also been noted in neonates with AVS with secondary HLHS [47][48][49]. A low-average to average IQ range in conjunction with mild deficits in a range of domains such as executive function and social cognition is common amongst children with wide-ranging diagnoses of CHD.…”

Perspective Chapter: Transcatheter Interventions in the Management of Aortic Valve Stenosis

“…These authors suggest comparison of in-hospital days and morbidity associated with both forms of therapy in future studies. However, single institutional studies differ in their conclusions with some suggesting comparable outcomes [92][93][94] and others favoring surgery [94][95][96]. Therefore, the author favors BAV because of considerable occurrence of mortality, both early and late, universal morbidity and the necessity for reoperation seen with surgical valvotomy.…”