Surgical aortic valvuloplasty in children and adolescents with aortic regurgitation: Acute and intermediate effects on aortic valve function and left ventricular dimensions
ABSTRACT Surgical aortic valvuloplasty is increasingly employed in the management of children and adolescents with aortic regurgitation, but the durability of this approach and factors associated with outcome are not well defined.
From 1989 to 2005, a total of 81 patients younger than 19 years with moderate or severe aortic regurgitation underwent surgical aortic valvuloplasty. Aortic regurgitation was congenital in 20 cases, after treatment of aortic stenosis in 30, from other injuries to the aortic valve in 12, and from other causes in 19. Eighteen patients had moderate or severe aortic stenosis. Preoperative left ventricular end-diastolic dimension z score was 4.9 +/- 2.7.
After surgical aortic valvuloplasty with various techniques, including pericardial leaflet augmentation in 80%, aortic regurgitation was improved in 77 patients and was mild or less in 68. Ten of 18 patients with moderate or severe aortic stenosis before repair had a decrease to mild, whereas 2 had progression from mild to moderate. Left ventricular end-diastolic dimension z score decreased by 2.9 +/- 2.1 (P < .001). During follow-up (median 4.7 years), 33 patients underwent aortic valve reinterventions, including aortic valve replacement in 25. Estimated freedoms from aortic valve replacement were 72% +/- 6% at 5 years and 54% +/- 9% at 7.5 years and were shorter in patients with moderate or severe aortic stenosis before surgical aortic valvuloplasty. Among surviving patients who did not undergo aortic valve replacement, aortic regurgitation at follow-up was moderate in 21 and trivial or mild in 34; left ventricular and aortic root dimensions were preserved.
Surgical aortic valvuloplasty is a valid option with good intermediate results for children and adolescents with aortic regurgitation from a variety of causes, particularly for patients with less than moderate aortic stenosis.
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ABSTRACT: To compare outcomes after surgical valvuloplasty and balloon dilatation of the aortic valve in neonates and infants. Surgical techniques of aortic valve repair have improved and there is today controversy on the best approach to treat neonatal congenital aortic valve stenosis. Retrospective review of data and follow up of 123 consecutive neonates and infants (35 females, 88 males) undergoing intervention for congenital aortic stenosis. From 1977 to 2009, 123 consecutive neonates (< 30 days) and infants (31 days-1 year) underwent relief of congenital aortic stenosis. Median age at procedure was 27 days (6-76 days). Twenty year survival was 80±7%. Fifty-four patients required a re-intervention and freedom from re-intervention was 55±6% at 10 years and 40±6% at 20 years. By multivariate analysis, having the relief of stenosis by balloon valvuloplasty and undergoing initial treatment as a neonate were predictive of re-intervention. Freedom from re-intervention at 5 years was 27% after balloon valvuloplasty vs 65% after surgery. At latest follow-up, an additional 16 patients had moderate or severe stenosis and 8 had regurgitation. Freedom from re-intervention or stenosis was 39±5% at 15 years. By multivariate analysis, balloon valvuloplasty (p<0.001) and treatment as a neonate (p=0.003) were again predictive of stenosis or reintervention. Thirty-five patients ultimately needed a valve replacement. Significant predictor of the requirement of valve replacement was unicuspid aortic valve (p<0.001). Freedom from valve replacement was 55±7% at 20 years. Surgical valvuloplasty remains the best approach to treat neonates and infants with congenital aortic stenosis. After surgery, a higher proportion of patients remain free of reintervention than after interventional catheterisation and the relief of their stenosis last longer.Journal of the American College of Cardiology 08/2013; 62(22). DOI:10.1016/j.jacc.2013.07.052 · 15.34 Impact Factor
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ABSTRACT: The durability of valve-sparing aortic root procedures with aortic regurgitation due to leaflet disease is questioned. Here, we review our experience in combined aortic root and valve reconstruction in children and young adults. All valve-sparing aortic root procedures from 2000 to 2012 were reviewed, and patients with aortic valve repair beyond resuspension were included. Root procedures were classified as replacement with reimplantation, root remodeling, or aortic annular and sinotubular junction stabilization. The primary end point was structural valve deterioration, a composite of aortic valve reoperation and/or moderate or greater regurgitation at follow-up. Thirty-four patients were included during the study period. The surgery consisted of reimplantation in 13 patients, remodeling in 16 patients, and annular and sinotubular junction stabilization in 5 patients. Valve repair consisted of leaflet procedures in 26 patients and subannular reduction in 15 patients. During a median follow-up of 4.2 months (range, 2 weeks-8 years), there were 5 reoperations for aortic valve replacement due to aortic regurgitation, and 2 patients presented with moderate or greater regurgitation. Freedom from structural valve deterioration was 70.1% ± 10.3% at 1 year and remained stable thereafter, although it was significantly worse in the reimplantation group (P = .039). A more severe degree of preoperative aortic regurgitation (P = .001) and smaller graft to aortic annulus ratio (P = .003) were predictors of structural valve deterioration. Valve-sparing root and valve reconstruction can be done with low operative risk and allows valve preservation in most patients. These data should question the assumption that reimplantation is superior when associated with complex valve reconstruction.The Journal of thoracic and cardiovascular surgery 02/2014; 147(6). DOI:10.1016/j.jtcvs.2014.02.055 · 3.41 Impact Factor
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ABSTRACT: The short-term surgical results for mixed aortic valve disease (MAVD) and the long-term effects on the left ventricle (LV) are unknown. Retrospective review identified patients with at least both moderate aortic stenosis (AS) and aortic regurgitation (AR) before surgical intervention. A one-to-one comparison cohort of patients with MAVD not referred for surgical intervention was identified. The 45 patients in this study underwent surgical management for MAVD. A control group of 45 medically managed patients with MAVD also was identified. Both groups had elevated LV end-diastolic volume (EDV), elevated LV mass, a normal LV mass:volume ratio (MVR), and a normal ejection fraction. Both groups had diastolic dysfunction shown by early diastolic pulsed-Doppler mitral inflow/early diastolic tissue Doppler velocity z-score. The LV end-diastolic pressure (EDP) was correlated with age (R = 0.4; p = 0.03) and LV MVR (R = 0.4; p = 0.03) but not with AS, AR, or the score combining gradient and LV size. As shown by 6- to 12-month postoperative echocardiograms, aortic valve gradients and AR significantly improved (gradient 65 ± 17 to 28 ± 18 mmHg, p = 0.01; median regurgitation grade moderate to mild; p < 0.01), LV EDV normalized, and LV mass significantly improved (p < 0.01). Diastolic dysfunction was unchanged. Symptoms did not correlate with any measured parameter, but the preoperative symptoms resolved. In conclusion, despite diastolic dysfunction, systolic function is invariably preserved, and symptoms are not correlated with aortic valve function or LV EDP. Current surgical practice preserves LV mechanics and results in short-term improvement in valve function and symptoms.Pediatric Cardiology 02/2014; DOI:10.1007/s00246-014-0878-6 · 1.55 Impact Factor