Aortic valve repair

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

BACKGROUND

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.

METHODS

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.

RESULTS

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 < .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).

CONCLUSIONS

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.

The great debate series: surgical treatment of aortic valve abnormalities in children

This article is the latest in an EJCTS series entitled 'The Great Debates'. We have chosen the topic of aortic valve (AoV) surgery in children, with a focus on infants and neonates. The topic was selected due to the significant challenges that AoV problems in the young may present to the surgical team. There are many areas of active controversy, despite the vast accumulated world experience. We have tried to incorporate many of these issues in the questions posed, not claiming to be all-inclusive. The individuals invited to this debate are experts in paediatric valve surgery, with broad and successful clinical experiences on multiple continents. We hope that the facts and opinions presented in this debate will generate interest and discussion and perhaps prove useful in decision-making for future complex valve cases.

Timing of aortic valve intervention in pediatric chronic aortic insufficiency

The timing of aortic valve intervention (AVI) in pediatric patients with chronic aortic insufficiency (AI) is largely based on adult experience, which is fraught with uncertainty and controversy. Current adult guidelines in the absence of symptoms use left ventricular (LV) systolic function and LV dimensions to guide AVI timing, with few studies translating these recommendations to pediatric patients. This article reviews the current guidelines for AVI timing in chronic AI along with the emerging data for pediatric patients.

The Ross, Konno, and Ross-Konno operations for congenital left ventricular outflow tract abnormalities

Operations for left ventricular outflow tract abnormalities are centred on hemodynamic conditions that relate to subvalvar stenosis, valvar stenosis/regurgitation, aortic annular hypoplasia, and supravalvar aortic stenosis. Operative interventions over the years have evolved because the intervening outcomes proved to be unsatisfactory. The resection for subvalvar aortic stenosis has progressed from a fibrous "membrane" resection to a more extensive fibromuscular resection. Operative solutions for valvar aortic stenosis and regurgitation have resulted in operative interventions that depend on simple commissurotomy, leaflet extensions, prosthetic mechanical valve replacement, biologic valve replacement, including the pulmonary autograft, and operations to treat aortic annular stenosis. Although there are enthusiastic proponents for all of these strategies, the fact remains that none have proven to be curative; patients can expect to undergo further procedures during their lifetimes. The short- and mid-term solutions to these left ventricular outflow tract abnormalities have improved based on operations that have been attended by increasing operative complexity. The purpose of this review is to chronicle the operative steps of the Ross operation, the Konno-Rastan operation, the modified Konno operation, the Ross-Konno operation, and the modified Ross-Konno operation.

Aortic valve repair: 49 year follow-up

This case report reveals an encouraging long-term follow-up of an aortic valve repair performed in 1962 by Sir Brian Barrett-Boyes. At last follow-up in 2011, 49 years after aortic valve repair, there was only trivial aortic regurgitation. This length of follow-up is considerably longer than that which currently exists in the literature for aortic valve repair.

Surgical valvuloplasty versus balloon aortic dilation for congenital aortic stenosis: are evidence-based outcomes relevant?

BACKGROUND

For children with congenital aortic stenosis (AS) who are selected for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter balloon aortic dilation (BAD). A retrospective study was undertaken to compare the effectiveness of BAD versus SAV, evaluating the long-term survival, incidence of aortic valve restenosis or aortic insufficiency (AI) or both, and freedom from reoperation for repeated valve repair or replacement. Neonates less than 2 months of age were excluded from this comparison.

METHODS

We reviewed the outcomes of children undergoing repair by SAV (n = 89) and BAD (n = 69) at our institution during a recent 20-year period. Clinical and echocardiographic follow-up were analyzed. The patient groups were compared with regard to the persistence or recurrence of postoperative aortic gradients and valve insufficiency and valve-related reintervention, including aortic valve replacement (AVR).

RESULTS

There was no significant difference between the groups with respect to mean age, body surface area, valve anatomy, sex, and preoperative gradients. Our data demonstrate that gradient reduction, AI, and the need for reintervention were worse for BAD. Aortic gradients at last follow-up were similar in both cohorts, but return of a significant gradient occurred sooner for patients who had BAD. Aortic gradient at discharge was significantly better for the patients who underwent SAV. Kaplan-Meier analysis showed that at 10 years, comparison of SAV and BAD was as follows: freedom from reintervention, 72% versus 53% (p = 0.02) and freedom from AVR, 80% versus 75% (p = 0.32).

CONCLUSIONS

BAD yields less gradient reduction, more postprocedural AI, and a shorter interval between initial and subsequent reintervention than does SAV. Our results demonstrate that SAV is safe and effective and that residual gradients and degree of AI are low. After SAV, the need for AVR can usually be delayed until the child is significantly older. The long-term functional stability after SAV is excellent. BAD in comparison is associated with an increased frequency and severity of AI and the need for earlier reintervention and valve replacement. SAV should be offered to all patients beyond the newborn period because it gives superior and longer lasting palliation.

[Tissue engineering of heart valves]

With the introduction of heart valve prostheses cardiac valvular disease has become much more accessible to therapeutic options. However, currently available prostheses display significant limitations, such as limited long-term durability (biological prostheses) and a long-term necessity for anticoagulation therapy. Hence, alternative prosthesis types have been extensively explored in recent years particularly aiming at the development of vital and regenerative prostheses by means of tissue engineering. In the scientific field, different competing concepts have been introduced, including biological or synthetic scaffolds which can be further enhanced by cellular or extracellular components to promote further in vivo development of the prosthesis after implantation. Nowadays, decellularized donor heart valves are among the most advanced prosthesis types experiencing growing clinical attention and widespread use.

Aortic valve repair for congenital and balloon-induced aortic regurgitation

Current techniques for aortic valve replacement in the child carry multiple disadvantages. Longer-term follow-up of the Ross procedure has documented disappointing late results for an increasing proportion of patients. Many challenges continue to face the development of a tissue-engineered valve with growth potential. In this setting, aortic valve repair is a useful temporizing procedure that allows a child to have an excellent quality of life, free from the need for anticoagulation and the risk of thromboembolism. Repair techniques are primarily based on the use of autologous pericardium to extend leaflets and support prolapsing leaflets. These methods appear to be particularly applicable in the setting of balloon-induced aortic valve regurgitation. An increasing number of centers are reporting satisfactory midterm results with aortic valve repair.

Current Perspective on Aortic Valve Repair and Valve-Sparing Aortic Root Replacement

Aortic valve repair and valve-sparing aortic root replacement are attractive concepts because they offer the possibility of valve competence without structural deterioration due to nonviability and they preclude the need for anticoagulation. Enthusiasm for aortic valve repair has waxed and waned over the past 45 years due in part to the inherent technical difficulties and poor mid-term results. Renewed interest in the concept of aortic valve repair has paralleled the development of valve-sparing aortic root replacement over the last 20 years. A current perspective on aortic valve repair and valve-sparing aortic root replacement is presented in the following review. Historical background, indications for repair, technical considerations, and outcomes data are discussed.