Long-Term Results of Balloon Valvuloplasty as Primary Treatment for Congenital Aortic Valve Stenosis: a 20-Year Review

Comparison between transcatheter versus surgical intervention for pediatric aortic valvular stenosis: a multicenter study in Japan

It is controversial whether children with isolated aortic valvular stenosis (vAS) initially undergo transcatheter or surgical aortic valvuloplasty (BAV or SAV). This multicenter retrospective case-control study aimed to explore outcomes after BAV or SAV for pediatric vAS. We studied children (aged < 15 years) with vAS treated at 4 tertiary congenital heart centers, and compared the rates of survival, reintervention, and valve replacement between patients with BAV and SAV. A total of 73 subjects (BAV: N = 52, SAV: N = 21) were studied. Age and aortic annulus z-score at the first presentation were 85 (26-530) days and - 0.45 (- 1.51-0.59), respectively. During the follow-up period of 121 (47-185) months, rates of 10-year survival (BAV: 88% vs. SAV: 92%, P = 0.477), reintervention (BAV: 58% vs. SAV: 31%, P = 0.626), and prosthetic/autograft valve replacement (BAV: 21% vs. SAV: 19%, P = 0.563) did not differ between the groups. Freedom from reintervention rate significantly correlated with aortic annulus z-score (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.49-0.88, P = 0.005), and freedom from prosthetic/autograft valve replacement rate significantly correlated to the degree of aortic regurgitation after the first intervention (HR: 4.58, 95% CI 1.19-17.71, P = 0.027). Propensity score-matched analysis (N = 16) did not show the differences in survival and reintervention rates between the groups. Long-term survival was acceptable, and the rates of freedom from reintervention and prosthetic/autograft valve replacement were comparable between children with vAS who underwent BAV and SAV.

Surgical valvotomy versus balloon dilatation for children with severe aortic valve stenosis: a systematic review

Aim: To evaluate outcomes of interventions for severe aortic valve stenosis (AS), whether it is done by surgical aortic valvotomy (SAV) or balloon aortic dilatation (BAD). Results: Eleven studies with total number of 1733 patients; 743 patients had SAV, while 990 patients received BAD. There was no significant difference in early mortality (odds ratio [OR]: 0.96, p = 0.86), late mortality (OR: 1.28, p = 0.25), total mortality (OR: 1.10, p = 0.56), and freedom from aortic valve replacement (OR: 1.00, p = 1.00). Reduction of aortic systolic gradient was significantly higher in the SAV group (OR: 2.24, p = 0.00001), and postprocedural AR rate was lower in SAV group (OR: 0.21, p = 0.00001). Conclusion: SAV is associated with better reduction of aortic systolic gradient and lesser post procedural AR which reduce when compared with BAD.

Trajectory of Left Ventricular Remodeling in Children With Valvar Aortic Stenosis Following Balloon Aortic Valvuloplasty

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Background:

Aortic valve stenosis is the most common type of congenital left ventricular (LV) outflow tract obstruction. Balloon aortic valvuloplasty (BAV) has become the first-line treatment pathway in many centers. Our aim was to assess the trajectory of LV remodeling following BAV in children and its relationship to residual aortic stenosis (AS) and insufficiency (AI).

Methods:

Children <18 years of age who underwent BAV for isolated aortic stenosis from 2004 to 2012 were eligible for inclusion. Those with AI before BAV, other complex congenital heart lesions, or <2 accessible follow-up echocardiograms were excluded. Baseline and serial echocardiographic data pertaining to aortic valve and LV size and function were retrospectively collected through December 2017 or the first reintervention. Longitudinal data was assessed using per-patient time profiles with superimposed trend lines using locally estimated scatterplot smoothing. Associations with reintervention or death were also evaluated.

Results:

Among the 98 enrolled children, the median (interquartile range) age at BAV was 2.8 months (0.2–75). The median (interquartile range) follow-up was 6.8 years (1.9–9.0). Children with predominantly residual AI (n=11) demonstrated progressive increases in their LV end-diastolic dimension Z score within the first 3 years after the BAV, followed by a plateau (P<0.001). Their mean LV circumferential and longitudinal strain values remained within the normal range but lower than in the non-AI group (P<0.001 and P=0.001, respectively). Children with predominantly residual aortic stenosis (n=44) had no changes in LV dimensions but had a rapid early increase in mean LV circumferential and longitudinal strain. The cumulative proportion (95% CI) of reintervention at 5 years following BAV was 33.7% (23.6%–42.4%).

Conclusions:

Our study demonstrates that LV remodeling occurs mainly during the first 3 years in children with predominantly residual AI after BAV, with no subsequent significant functional changes over the medium term. These data improve our understanding of expected patient trajectories and thus may inform decisions on the timing of reintervention.

Results of balloon and surgical valvuloplasty in congenital aortic valve stenosis: A 19-year, single-center, retrospective study

Background

This study aims to compare the success, complications, and long-term outcomes of aortic balloon valvuloplasty and surgical aortic valvuloplasty in pediatric patients with congenital aortic valve stenosis.

Methods

Between March 2000 and October 2019, a total of 267 procedures, including 238 balloon valvuloplasties and 29 surgical valvuloplasties, in 198 children (135 males, 63 females; mean age: 57.4±62.6 months; range, 0.03 to 219 months) were retrospectively analyzed. The hospital records, echocardiographic images, catheterization data, angiography images, and operative data were reviewed.

Results

Aortic regurgitation was mild in 73 patients before balloon valvuloplasty, and none of the patients had moderate-to-severe aortic regurgitation. Compared to surgical valvuloplasty, the rate of increase in the aortic regurgitation after balloon valvuloplasty was significantly higher (p=0.012). The patients who underwent balloon valvuloplasty did not need reintervention for a mean period of 46±45.6 months, whereas this period was significantly longer in those who underwent surgical valvuloplasty (mean 80.5±53.9 months) (p=0.018). The overall failure rate was 8%. Moderate-to-severe aortic regurgitation was the most important complication developing due to balloon valvuloplasty in the early period (13%). All surgical valvuloplasties were successful. The mean length of hospitalization after balloon valvuloplasty was significantly shorter than surgical valvuloplasty (p=0.026). During follow-up, a total of 168 patients continued their follow-up, and a reinterventional or surgical intervention was not needed in 78 patients (47%).

Conclusion

Aortic balloon valvuloplasty can be repeated safely and helps to eliminate aortic valve stenosis without needing sternotomy. Surgical valvuloplasty can be successfully performed in patients in whom the expected benefit from aortic balloon valvuloplasty is not achieved.

[Prosthetic repair of aortic valve cusps with autopericardium in children. State of the art and prospects]

According to the results of modern researchers, the main techniques used in congenital pathology of the aortic valve in children include balloon catheter dilatation of the aortic valve, surgical valvuloplasty, the Ross procedure and replacement of the aortic valve with a mechanical prosthesis. Many surgeons point out that these techniques in congenital pathology of the aortic valve yield suboptimal results. This is often due to the lack of a clear-cut definition between surgeons as to what operation should be performed in a particular age group. According to the reports of the majority of researchers, biological prostheses undergo early degeneration and structural changes in paediatric cardiac surgery and yield the worst results. Comparing the main techniques, optimal haemodynamics is observed after the Ross procedure. A disadvantage of this operation is the necessity of repeat intervention on the right ventricular outflow tract, which is required in 20 to 40%. Concomitant surgery of the mitral valve and/or aortic arch during the Ross procedure significantly increases the lethality and the risk of postoperative complications. Compared with an adult cohort of patients, children after prosthetic repair of the aortic valve using a mechanical prosthesis are more often found to have postoperative complications and a higher mortality rate. Yet another problem encountered in paediatric valve surgery is the unavailability of commercial prostheses sized ?19 mm. The duration of the intraoperative parameters for reconstructions of the aortic valve, the Ross procedure, and replacement of the aortic valve by the results of many studies averagely amounts to 74±34 min, 100±56 min, and 129±71 min, respectively. Yet another method which can be used for neocuspidization of the aortic valve in reconstructive surgery of the aortic root in paediatric patients is the use of glutaraldehyde-treated autologous pericardium. In our opinion, given the simplicity of the procedure, duration of the intraoperative parameters, and acceptable initial results reported by some researchers, the Ozaki procedure may be performed in children.

Treatment of valvular aortic stenosis in children: a 20-year experience in a single institution

OBJECTIVES

This study presents short- and long-term follow-up after treatment for isolated valvular aortic stenosis in children with surgical valvotomy as the preferred 1st intervention.

METHODS

All patients aged 0-18 years treated between 1994 and 2013 at our centre were reviewed regarding the mode of first treatment, mortality, reinterventions and the need for aortic valve replacement.

RESULTS

A total of 113 patients were identified in local registries. There were 44 neonates, 31 infants and 38 children. The mean follow-up period was 11 years (range 2-22 years). No early deaths and only 2 late deaths were reported. Of the 113 patients, 92 patients had open surgical valvotomy as the 1st intervention. Freedom from reintervention was 80%, 69%, 61%, 57% and 56% at 1, 5, 10, 15 and 20 years, respectively. The main indication for reintervention was valvular stenosis. Freedom from aortic valve replacement was 67%.

CONCLUSIONS

Surgical valvotomy of aortic stenosis in this long-term follow-up study resulted in no 30-day mortality and <1% late mortality. Reinterventions were common, with 38% of the patients having further surgery or catheter treatment of the aortic valve before the age of 18 years. Among the 40 patients aged 18 years or older at follow-up, 45% had had the aortic valve replaced. Our data do not allow comparison of catheter and surgical treatment, but, based on these results, we find no reason to change our current policy of surgical treatment as 1st intervention in patients with isolated valvular aortic stenosis.

Comparison of Balloon Dilatation and Surgical Valvuloplasty in Non-critical Congenital Aortic Valvular Stenosis at Long-Term Follow-Up

The two main modalities used for congenital aortic valvular stenosis (AVS) treatment are balloon aortic valve dilatation (BAD) and surgical aortic valvuloplasty (SAV). This study evaluates residual and recurrent stenosis, aortic regurgitation (AR) development/progression, reintervention rates, and the risk factors associated with this end point in patients with non-critical congenital AVS who underwent BAD or SAV after up to 18 years of follow-up. From 1990 to 2017, 70 consecutive interventions were performed in patients with AVS, and 61 were included in this study (33 BADs and 28 SAVs). There were no significant differences in age, sex distribution, PSIG, and AR frequency between the BAD and SAV groups. Bicuspid valve morphology was more common in the BAD group than the SAV group. There was no statistically significant difference between PSIGs and AR development or progression after intervention at the immediate postoperative echocardiography of patients who underwent BAD or SAV (p = 0.82 vs. p = 0.29). Patients were followed 6.9 ± 5.1 years after intervention. The follow-up period in the SAV group was longer than that of the BAD group (9.5 ± 5.4 vs. 5.5 ± 4.4 years, p = 0.003). There was no statistically significant difference in the last echocardiographic PSIG between patients who underwent SAV or BAD (51.1 ± 33.5 vs. 57.3 ± 35.1, p = 0.659). Freedom from reintervention was 81.3% at 5 years and 57.5% at 10 years in the BAD group and 95.5% at 5 years and 81.8% at 10 years in the SAV group, respectively (p = 0.044). There was no difference in postprocedural immediate PSIG and last PSIG at follow-up and the development/progression of AR between patients who were treated with BAD versus SAV. However, long-term results of SAV were superior to those of BAD, with a somewhat prolonged reintervention interval.

Current surgical strategies and techniques of aortic valve diseases in children

While the long-term outcome of surgical aortic valvotomy (SAV) appears to be better than that of balloon aortic valvuloplasty (BAV) as the primary procedure of aortic valve stenosis, the surgical strategies and techniques of treating aortic valve disease in children in other situations remain controversial. Valve repair should be first considered while replacement is still unavoidable in some cases, and new repair techniques developed by innovative surgeons are gradually becoming adopted. Some complex repair procedures such as cusp extension, leaflet replacement/reconstruction have provided satisfactory outcomes. The Ozaki technique replaces aortic valve leaflets with glutaraldehyde-treated autologous pericardium instead of replacing the valve entirely. Special instruments have been developed to make the Ozaki technique more reproducible and standardized. Neonates and infants undergoing aortic valve replacement (AVR) are a high-risk group, where repair should be the primary consideration rather than replacement. Several systematic reviews reveal that all currently available aortic valve substitutes such as pulmonary autograft, mechanical prosthesis, homograft and bioprosthesis are associated with suboptimal results in children, but pulmonary autograft appeared to be superior with high freedom from reintervention and better hemodynamic performance. The strategy for treatment of aortic valve disease should be specifically analyzed based on the brief of being beneficial for children.

Hybrid Balloon Valvuloplasty for the Treatment of Severe Congenital Aortic Valve Stenosis in Infants

BACKGROUND

Surgical or percutaneous interventional treatment of severe congenital aortic valve stenosis (CAS) in early infancy remains challenging. This single-center, retrospective study analyzed midterm outcomes of a hybrid balloon valvuloplasty procedure through the ascending aorta by way of median sternotomy, including cases with improved technique.

METHODS

Included were 45 consecutive infants (aged <90 days) with CAS and selected for biventricular repair who underwent hybrid balloon valvuloplasty in a hybrid or ordinary operating room from October 2010 to March 2016. Patients were assessed at 1, 3, 6, and 12 months and yearly thereafter.

RESULTS

Hybrid balloon valvuloplasty was successful in all patients, with the last 8 treated in an ordinary operating room under only echocardiography guidance with a new sheath. Thirty-two patients were successfully rescued from low heart rate or left ventricular systolic dysfunction, or both, by cardiac massage under direct visualization; none required cardiopulmonary bypass. The degree of new aortic insufficiency was mild in 7 patients and changed from mild to moderate in 1 patient. Aortic valve pressure gradient decreased from 70.6 ± 17.5 mm Hg preoperatively to 15.2 ± 4.2 mm Hg immediately postoperatively (p < 0.001). Fluoroscopy time was 4.8 ± 2.3 minutes. At a median of 32.1 months (range, 1 to 68 months) follow-up, all patients were alive and healthy. Aortic valve pressure gradient remained low (19.1 ± 5.2 mm Hg). Left ventricular ejection fraction increased from 0.515 ± 0.134 (range, 0.21 to 0.70) preoperatively to 0.633 ± 0.035 (range, 0.58 to 0.75; p < 0.001). No aortic insufficiency developed, and no patient required reintervention.

CONCLUSIONS

For infants with severe CAS, hybrid balloon valvuloplasty through the ascending aorta by way of a median sternotomy appears efficacious and safe up to midterm follow-up.

Surgical Aortic Valvuloplasty Versus Balloon Aortic Valve Dilatation in Children

Balloon aortic valve dilatation (BAD) is assumed to provide the same outcomes as surgical aortic valvuloplasty (SAV). However, the development of precise modern surgical valvuloplasty techniques may result in better long-term durability of the aortic valve repair. This review of the recent literature suggests that current SAV provides a safe and durable repair. Furthermore, primary SAV appears to have greater freedom from reintervention and aortic valve replacement when compared to BAD.