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Frankel WC, Robinson JA, Roselli EE, Unai S, Tretter JT, Fuller S, Nelson JS, Ghobrial J, Svensson LG, Pettersson GB, Najm HK, Karamlou T. Lifetime Management of Adolescents and Young Adults with Congenital Aortic Valve Disease. Ann Thorac Surg 2024:S0003-4975(24)00461-2. [PMID: 38871162 DOI: 10.1016/j.athoracsur.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/26/2024] [Accepted: 04/24/2024] [Indexed: 06/15/2024]
Abstract
In this invited expert review, we focus on evolving lifetime management strategies for adolescents and young adults with congenital aortic valve disease, acknowledging that these patients often require multiple interventions during their lifetime. Our goal is to preserve the native aortic valve when feasible. Leveraging advanced multimodality imaging, a detailed assessment of the aortic valve and root complex can be obtained, and a surgically approach tailored to an individual patient's anatomy and pathology can be used. In turn, aortic valve repair and reconstruction can be offered to a greater number of patients, either as a definitive strategy or as a component of a staged strategy to delay the need for aortic valve replacement until later in life when more options are available.
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Affiliation(s)
- William C Frankel
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin A Robinson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin T Tretter
- Department of Pediatric Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer S Nelson
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Joanna Ghobrial
- Department of Pediatric Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
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Danial P, Moiroux-Sahraoui A, Nelly A, Pontailler M, Gaudin R, Lansac E, Pavy C, Bonnet D, Vouhé P, Raisky O. Outcomes of aortic valve repair in children stratified by complexity: Which outcome for which lesion? J Thorac Cardiovasc Surg 2024; 167:1533-1542.e6. [PMID: 38008207 DOI: 10.1016/j.jtcvs.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE Aortic valvuloplasty frequency has significantly increased over the past 15 years. Surgical repair varies in complexity depending on valvular lesions. Our aim is to report results on the whole spectrum of aortic valvuloplasty techniques. METHODS All children who consecutively underwent aortic valvuloplasty for aortic stenosis and/or aortic insufficiency between January 2006 and December 2020 at Necker Sick Children's Hospital (Paris, France) were included in a retrospective cohort study. Aortic valvuloplasty techniques were classified into 3 difficulty levels: (1) simple repair, corresponding to commissurotomy and/or shaving in aortic stenosis (AS) in neonates (group 1) and children >1 month (group 2); (2) intermediate-complexity repair, corresponding to commissuroplasty, leaflet resuspension, and fenestration closure in aortic insufficiency (leaflet prolapse in connective tissue disease, isolated leaflet prolapse and Laubry-Pezzi groups); and (3) complex repair requiring a pericardial patch to restore a functional aortic valve in mixed aortic valve disease (bicuspidization with neocommissure and cusp extension groups). RESULTS During the study period, 324 children underwent aortic valvuloplasty. Survival and freedom from aortic valve reintervention at 10 years were, respectively, 86.1% and 50.9% in neonates with AS, 95.2% and 71.7% in children >1 month with AS, 93.8% and 79.5% in leaflet prolapse in connective tissue disease, 97.7% and 91.9% in isolated leaflet prolapse, 100% and 88% in those with Laubry-Pezzi syndrome, 97.4% and 84.8% in bicuspidization with neocommissure, and 100% and 54.2% in the cusp extension. CONCLUSIONS Durability of aortic valvuloplasty techniques is satisfactory and offers the possibility to delay the Ross procedure, regardless of the lesion's complexity.
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Affiliation(s)
- Pichoy Danial
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France; INI-CRCT, F-CRIN, Nancy, France
| | - Alexander Moiroux-Sahraoui
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Asma Nelly
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Margaux Pontailler
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Régis Gaudin
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Emmanuel Lansac
- Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Carine Pavy
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Damien Bonnet
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Pascal Vouhé
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, Necker Sick Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France.
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Sengupta A, Gauvreau K, Marx GR, Colan SD, Newburger JW, Baird CW, Del Nido PJ, Nathan M. Residual Lesion Severity Predicts Midterm Outcomes After Congenital Aortic Valve Repair. Ann Thorac Surg 2023; 115:159-165. [PMID: 36075398 DOI: 10.1016/j.athoracsur.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND We sought to validate the technical performance score (TPS) as a predictor of midterm outcomes after congenital aortic valve repair. METHODS This was a single-center, retrospective review of consecutive patients who underwent aortic valve repair between January 1, 2011, and December 31, 2019. Predischarge echocardiograms were used to assign a TPS for each index operation as class 1, no aortic valve residua; class 2, minor aortic valve residua; or class 3, major aortic valve residua or predischarge reintervention for major residua. The primary outcome was postdischarge (late) unplanned aortic valve reintervention. Secondary outcomes included late mortality and at least moderate aortic regurgitation or stenosis at the latest follow-up or before the earliest reintervention. Associations between TPS and outcomes were assessed using competing risk, Cox proportional hazards, or logistic regression models, adjusting for preoperative patient- and procedure-related covariates. RESULTS Of 507 patients, there were 110 (21.7%) reinterventions, 22 (4.3%) deaths, and 67 (13.2%) cases of at least moderate aortic regurgitation or stenosis at the latest follow-up or earliest reintervention. On multivariable analysis, class 3 patients had a greater risk of reintervention (subdistribution hazard ratio, 2.6; 95% CI, 1.3-5.1; P = .005) and mortality (hazard ratio, 5.3; 95% CI. 1.1-25.2; P = .038) compared with class 1 patients. Adjusting for duration of follow-up, class 3 patients also had a greater risk of at least moderate aortic regurgitation or stenosis at the latest follow-up or earliest reintervention (odds ratio, 7.7; 95% CI, 2.5-24.2; P < .001) vs class 1 patients. CONCLUSIONS Patients with major residua after congenital aortic valve repair have significantly worse midterm outcomes compared with those with no residua, warranting closer follow-up.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Gerald R Marx
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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Fernández-Doblas J, Pamies-Catalán A, Abella RF. Cirugía de Ross y Ross-Konno en edad pediátrica: ¿es la edad un factor de riesgo? CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Alsoufi B, Knight JH, St. Louis J, Raghuveer G, Kochilas L. Are Mechanical Prostheses Valid Alternatives to the Ross Procedure in Young Children Under 6 Years Old? Ann Thorac Surg 2022; 113:166-173. [PMID: 33359723 PMCID: PMC8219808 DOI: 10.1016/j.athoracsur.2020.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 11/26/2020] [Accepted: 12/09/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used. METHODS We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n = 84) or MP (n = 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes. RESULTS Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P = .24) or 15-year transplant-free survival (94.1% vs 87.5%, P = .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P = .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P = .78] vs 6.0 [95% confidence interval, 0.6-63.1; P = .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P = .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement. CONCLUSIONS Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve- and reoperation-related complications.
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Affiliation(s)
| | - Jessica H. Knight
- Department of Epidemiology and Biostatistics, University of Georgia College of Public Health
| | - James St. Louis
- Department of Pediatrics, University of Missouri-Kansas City
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Schulz A, Buratto E, Wallace FR, Fulkoski N, Weintraub RG, Brizard CP, Konstantinov IE. Outcomes of aortic valve repair in children resulting in bicuspid anatomy: is there a need for tricuspidization? J Thorac Cardiovasc Surg 2022; 164:186-196.e2. [DOI: 10.1016/j.jtcvs.2022.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/17/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
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Komarov RN, Puzenko DV, Isaev RM, Belov IV. [Prosthetic repair of aortic valve cusps with autopericardium in children. State of the art and prospects]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:191-198. [PMID: 33825748 DOI: 10.33529/angio2021119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- R N Komarov
- Department of Hospital Surgery of the Medical Faculty, I.M. Sechenov First Moscow Medical University of the RF Ministry of Public Health, Moscow, Russia; Department of Faculty Surgery #1, Institute of Clinical Medicine, I.M. Sechenov First Moscow Medical University of the RF Ministry of Public Health, Moscow, Russia; Department of Cardiosurgery, University Clinical Hospital #1, I.M. Sechenov First Moscow Medical University of the RF Ministry of Public Health, Moscow, Russia
| | - D V Puzenko
- Department of Cardiosurgery, University Clinical Hospital #1, I.M. Sechenov First Moscow Medical University of the RF Ministry of Public Health, Moscow, Russia
| | - R M Isaev
- Department of Hospital Surgery of the Medical Faculty, I.M. Sechenov First Moscow Medical University of the RF Ministry of Public Health, Moscow, Russia; Department of Faculty Surgery #1, Institute of Clinical Medicine, I.M. Sechenov First Moscow Medical University of the RF Ministry of Public Health, Moscow, Russia
| | - Iu V Belov
- Department of Hospital Surgery of the Medical Faculty, I.M. Sechenov First Moscow Medical University of the RF Ministry of Public Health, Moscow, Russia; Institute of Cardioaortic Surgery, Petrovsky National Research Centre of Surgery, Moscow, Russia
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Thakeb YM, Sakr S, El Sarawy E, Salem AM. Short-term competency of aortic valve repair in Egyptian patients. J Card Surg 2020; 35:598-602. [PMID: 31981423 DOI: 10.1111/jocs.14429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In recent years, repair techniques for diseased aortic valves have received increasing attention. This study reports the short-term outcome of aortic valve repair (AVr) for three pathologic categories: rheumatic heart disease, aortic regurgitations (ARs) from subarterial ventricular septal defect (VSD), and infective endocarditis in order achieve the valve competency. METHODS From January 2017 to March 2019, 30 patients underwent AVr with significant AR in the National Heart Institute (NHI) and Banha university. All patients underwent echocardiography before and after the procedure; 30 patients underwent AVr with significant AR, nine patients (30%) with juxta-arterial VSD, two patients (6.66%) with infective endocarditis (IE), and 19 patients (63.33%) with rheumatic aortic valve disease. For intraoperative transesophageal echocardiography and direct examination for better clarification of the anatomy and guidance of repair after cardiopulmonary bypass (CPB), annular repair, leaflet repair by shaving, plication, triangular resection, augmentation with the pericardium, and VSD closure were done. RESULTS Only three patients developed aortic incompetence grade II, no in-hospital mortality; however, we had 3 months later mortality for one patient with IE, only one patient with rheumatic heart disease progressed from grade II to grade IV aortic incompetence (AI) and aortic valve replacement was done so AVr was successfully done for the subaortic VSD, rheumatic, and IE patients instead of replacement of the valve. CONCLUSIONS In favor of AVr, good patient selection, amenable techniques for the suitable pathology will give a good target hence the aim of the work.
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Affiliation(s)
- Yosry M Thakeb
- Cardiothoracic Surgery Department, National Heart Institute, Giza, Egypt
| | - Samar Sakr
- Department of Biochemistry, Faculty of Science, Mansoura University, Mansoura, Egypt
| | - Emad El Sarawy
- Cardiothoracic Surgery Department, National Heart Institute, Giza, Egypt
| | - Alsayed M Salem
- Cardiothoracic Surgery Department, National Heart Institute, Giza, Egypt
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Rimmer L, Ahmad MU, Chaplin G, Joshi M, Harky A. Aortic Valve Repair: Where Are We Now? Heart Lung Circ 2019; 28:988-999. [DOI: 10.1016/j.hlc.2019.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/20/2019] [Accepted: 02/13/2019] [Indexed: 11/26/2022]
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Hofmann M, Schmiady MO, Burkhardt BE, Dave HH, Hübler M, Kretschmar O, Bode PK. Congenital aortic valve repair using CorMatrix ® : A histologic evaluation. Xenotransplantation 2017; 24. [PMID: 28940406 DOI: 10.1111/xen.12341] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/28/2017] [Accepted: 08/14/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The reconstruction of heart valves provides substantial benefits, particularly in the pediatric population. We present our experience using decellularized extracellular matrix (dECM, CorMatrix® ) for aortic valve procedures. METHODS We retrospectively reviewed the case histories of 6 patients (aged from 2 months - 14 years) who underwent surgery for severe aortic valve stenosis (n = 4) or regurgitation (n = 2). Aortic valve repair was performed on all patients using dECM as a leaflet replacement or leaflet extension. Follow-ups were performed using echocardiography. Reoperation was necessary in 4 cases, and the dECM was explanted and examined histologically and immunohistochemically. RESULTS The early post-operative period was uneventful, and the scaffold fulfilled the mechanical requirements. Significant valve insufficiency developed in 5 patients during the post-operative period (119-441 days postoperatively). In all specimens, only a migration of inflammatory cells was identified, which induced structural and functional changes caused by the chronic inflammatory response. CONCLUSIONS Our results suggest a mixed immunological response of remodeling and inflammation following the implantation. The expected process of seeding/migration and remodeling of the bioscaffold into the typical 3-layered architecture were not observed in our explanted specimens.
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Affiliation(s)
- Michael Hofmann
- Division of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin O Schmiady
- Division of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Barbara E Burkhardt
- Division of Pediatric Cardiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Hitendu H Dave
- Division of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Michael Hübler
- Division of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Oliver Kretschmar
- Division of Pediatric Cardiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Peter K Bode
- Institute of Surgical Pathology, University Hospital Zurich, Zurich, Switzerland
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Tweddell JS. Are complex aortic valve repairs a real alternative to replacement in children? Eur J Cardiothorac Surg 2017; 52:588-589. [DOI: 10.1093/ejcts/ezx177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
OBJECTIVES In this review, we will discuss aortic stenosis, aortic regurgitation, mitral regurgitation, and mitral stenosis. We will review the etiology, anatomy, pathophysiology, presentation, and treatment of aortic and mitral valve disease. Age and lesion specific treatments are outlined based on the severity of valve disease with an aim at long-term preservation of left ventricular function. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS Mitral and aortic valve disease leads to unique hemodynamic burdens that can impact left ventricular function, quality of life, and longevity. The primary challenge in the management of mitral and aortic valve disease is to apply appropriate medical management and identify that point in time at which the surgery is necessary. Although guidelines have been established for the management of aortic and mitral valve disease in adults, the challenges of early presentation, maintenance of growth potential, and apparent increased tolerance of hemodynamic burden in children makes decision making challenging.
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Stern KWD, White MT, Verghese GR, Del Nido PJ, Geva T. Intraoperative Echocardiography for Congenital Aortic Valve Repair: Predictors of Early Reoperation. Ann Thorac Surg 2015; 100:678-85. [PMID: 26138765 DOI: 10.1016/j.athoracsur.2015.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/26/2015] [Accepted: 05/01/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND We sought to identify transesophageal echocardiography (TEE) predictors of early reoperation for recurrent aortic regurgitation (AR) after cardiopulmonary bypass (CPB) in patients undergoing repair for congenital aortic valve disease. METHODS We analyzed post-CPB TEEs in patients with congenital aortic valve disease undergoing repair for predominant AR. Case patients underwent reoperation for recurrent AR within 2 years, whereas control patients were free from reoperation for more than 3 years. RESULTS Case patients (n = 22; median time to reoperation 0.3 years) and control patients (n = 22; median freedom from reoperation ≥4.4 years) were similar for demographic characteristics, aortic dimensions, and preoperative AR grade. Among post-CPB TEE variables, univariate logistic regression analysis identified shorter coaptation height (odds ratio [OR] for 1-mm increase 0.72, 95% confidence interval [CI]: 0.54 to 0.95; p = 0.02), decreased ratio of coaptation height to annulus diameter (OR for a 5% decrease 1.37, 95% CI: 1.06 to 1.77; p = 0.02), and increased percentage difference (%diff) between longest and shortest coaptation lengths in a short-axis view (OR for 10% increase 1.84, 95% CI: 1.15 to 2.92; p = 0.01) as risk factors for early reoperation for recurrent AR. Multivariable analysis identified %diff in short-axis coaptation lengths as the strongest post-CPB TEE predictor (area under receiver operator curve = 0.743). The sensitivity and specificity of a %diff of 50% were 0.45 and 0.91, whereas a %diff of 30% had a sensitivity of 0.75 and specificity of 0.67. CONCLUSIONS Coaptation asymmetry, measured as increased %diff in short-axis coaptation lengths on post-CPB TEE, is associated with early reoperation for recurrent AR after congenital valve repair.
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Affiliation(s)
- Kenan W D Stern
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - Matthew T White
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - George R Verghese
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Aroca Á, Polo L, González Á, Rey J, Greco R, Villagrá F. Estenosis congénita a la salida del ventrículo izquierdo. Técnicas y resultados. CIRUGIA CARDIOVASCULAR 2014. [DOI: 10.1016/j.circv.2014.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Kandakure P, Prior N, Soda G, Lim J, Dhannapuneni R, Venugopal P, Alphonso N. Outcome of a Repair-Oriented Strategy for the Aortic Valve in Children. World J Pediatr Congenit Heart Surg 2014; 5:191-9. [DOI: 10.1177/2150135113513476] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: We sought to evaluate the mid-term results of a repair-oriented strategy of the aortic valve in children. Methods: Between February 2007 and November 2011, we performed 39 aortic valve repairs in children. Median age and weight at surgery were 5.5 years (3 days-18 years) and 16.7 kg (2.7-83.5), respectively. A total of 11 (28%) patients had one or more prior surgical or interventional cardiologic procedures. Median intensive care unit and hospital stay were two (1-96) and five (3-96) days, respectively. Median and cumulative follow-up were 12.7 months (15 days-64 months) and 48.9 patient-years, respectively. Results: There were 3 (7.7%) early deaths all in patients undergoing additional complex cardiac procedures. Two (5.1%) patients required early surgical revision. Twenty-six (66%) patients had isolated or mixed aortic stenosis. The median gradient reduced from 62.4 (range 16-144) to 17.6 mm Hg (range 0-51.8), postoperatively ( P = .02). At last follow-up, the median gradient remained largely unchanged at 21.1 mm Hg (0-49; P = .02). Twenty-six (66%) patients had isolated or mixed aortic valve regurgitation (mild in 8 [20%], moderate in 15 [38%], and severe in 6 ([15%] patients). The degree of aortic regurgitation improved in all patients with moderate or severe aortic regurgitation ( P = .04). At last follow-up, two patients had moderate aortic regurgitation. Kaplan Meier freedom from reintervention in the survivors was 95% at three years. Conclusions: A repair-oriented strategy for the aortic valve in children has satisfactory early and mid-term results and remains a promising management option in children with aortic valve disease.
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Affiliation(s)
- Pramod Kandakure
- Cardiac Surgical Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Natasha Prior
- Cardiac Surgical Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Giri Soda
- Department of Cardiology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Joyce Lim
- Department of Cardiology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Ram Dhannapuneni
- Cardiac Surgical Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Prem Venugopal
- Cardiac Surgical Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Nelson Alphonso
- Queensland Paediatric Cardiac Service, Mater Children’s Hospital, Raymond Terrace, South Brisbane 4101, Australia
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Brancaccio G, Polito A, Hoxha S, Gandolfo F, Giannico S, Amodeo A, Carotti A. The Ross procedure in patients aged less than 18 years: The midterm results. J Thorac Cardiovasc Surg 2014; 147:383-8. [DOI: 10.1016/j.jtcvs.2013.02.037] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 11/18/2012] [Accepted: 02/13/2013] [Indexed: 10/27/2022]
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Bradley SM. Aortic Valve Insufficiency in the Teenager and Young Adult. World J Pediatr Congenit Heart Surg 2013; 4:397-402. [DOI: 10.1177/2150135113488781] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The contents of this article were presented in the session “Aortic insufficiency in the teenager” at the congenital parallel symposium of the 2013 Society of Thoracic Surgeons (STS) annual meeting. The accompanying articles detail the approaches of aortic valve repair and the Ross procedure.1,2 The current article focuses on prosthetic valve replacement. For many young patients requiring aortic valve surgery, either aortic valve repair or a Ross procedure provides a good option. The advantages include avoidance of anticoagulation and potential for growth. In other patients, a prosthetic valve is an appropriate alternative. This article discusses the current state of knowledge regarding mechanical and bioprosthetic valve prostheses and their specific advantages relative to valve repair or a Ross procedure. In current practice, young patients requiring aortic valve surgery frequently undergo valve replacement with a prosthetic valve. In STS adult cardiac database, among patients ≤30 years of age undergoing aortic valve surgery, 34% had placement of a mechanical valve, 51% had placement of a bioprosthetic valve, 9% had aortic valve repair, and 2% had a Ross procedure. In the STS congenital database, among patients 12 to 30 years of age undergoing aortic valve surgery, 21% had placement of a mechanical valve, 18% had placement of a bioprosthetic valve, 30% had aortic valve repair, and 24% had a Ross procedure. In the future, the balance among these options may be altered by design improvements in prosthetic valves, alternatives to warfarin, the development of new patch materials for valve repair, and techniques to avoid Ross autograft failure.
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Affiliation(s)
- Scott M. Bradley
- Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC, USA
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Siddiqui J, Brizard CP, Galati JC, Iyengar AJ, Hutchinson D, Konstantinov IE, Wheaton GR, Ramsay JM, d'Udekem Y. Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization. J Am Coll Cardiol 2013; 62:2134-40. [PMID: 23954309 DOI: 10.1016/j.jacc.2013.07.052] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/02/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to compare outcomes after surgical valvuloplasty and balloon dilation of the aortic valve in neonates and infants. BACKGROUND Surgical techniques of aortic valve repair have improved and there is today controversy on the best approach to treat neonatal congenital aortic valve stenosis. METHODS Retrospective review of data and follow-up of 123 consecutive neonates and infants (35 females, 88 males) undergoing intervention for congenital aortic stenosis. RESULTS From 1977 to 2009, 123 consecutive neonates (<30 days) and infants (31 days to 1 year) underwent relief of congenital aortic stenosis. Median age at procedure was 27 days (6 to 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 versus 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 re-intervention. 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. CONCLUSIONS 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 re-intervention than after interventional catheterization and the relief of their stenosis lasts longer.
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Wang C, Miao Q, Liu X, Li X. Surgery for Congenital Aortic Stenosis in Children With Left Ventricular Noncompaction. J Card Surg 2013; 28:465-6. [PMID: 23763604 DOI: 10.1111/jocs.12132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Chao Wang
- Department of Cardiac Surgery; Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences; Beijing China
| | - Qi Miao
- Department of Cardiac Surgery; Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences; Beijing China
| | - Xingrong Liu
- Department of Cardiac Surgery; Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences; Beijing China
| | - Xiaofeng Li
- Department of Cardiac Surgery; Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences; Beijing China
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Cox DA, Walton K, Bartz PJ, Tweddell JS, Frommelt PC, Earing MG. Predicting left ventricular recovery after replacement of a regurgitant aortic valve in pediatric and young adult patients: is it ever too late? Pediatr Cardiol 2013; 34:694-9. [PMID: 23052669 DOI: 10.1007/s00246-012-0529-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 09/12/2012] [Indexed: 11/28/2022]
Abstract
The management of pediatric and adolescent patients with pure aortic valve regurgitation remains challenging and controversial (Christos et al., Eur J Cardiothorac Surg 17:125-133, 2000; Gersony and Sommerville, ACC Curr J Rev 31:97-98, 2000; Hasaniya et al., J Thorac Cardiovasc Surg 127:970-974, 2004; Sabet et al., Mayo Clin 74:14-26, 1999; Tweddell et al., J Thorac Cardiovasc Surg 129:551-558, 2005). We evaluated pediatric and young adult patients who underwent aortic valve replacement (AVR) primarily for aortic regurgitation in an effort to identify preoperative echocardiographic variables that are predictive of left ventricular (LV) recovery following AVR. Twenty-one patients with severe aortic valve regurgitation who underwent AVR were identified. Retrospective chart review for each patient was performed and transthoracic echocardiograms prior to and 6-months after AVR were analyzed. Improvement in LV size based on preoperative LV end-systolic dimension index when compared to 6-months post-AVR was observed in 68% of the patients. Patients with persistent dilation of their left ventricles had a greater preoperative LV end-systolic dimension index (p ≤ 0.05), a greater preoperative LV end-systolic dimension z-score (p ≤ 0.002), and a lower preoperative ejection fraction (EF) (p ≤ 0.001). A similar trend was present between the two cohorts in regards to LV end-diastolic parameters (LV end-diastolic dimension index and z-score), with patients with abnormal LV size at 6-month follow-up having larger preoperative dimensions. Increasing LV systolic dimensions and declining EF appear to be predictors of poor LV recovery following AVR in pediatric and young adult patients. LV end-systolic indices appear to be more predictive than LV end-diastolic indices. AVR should be performed prior to severe LV enlargement defined as an LV end-systolic dimension z-score >4.5.
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Affiliation(s)
- Daniel A Cox
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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21
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Aortic valve repair: 49 year follow-up. Heart Lung Circ 2013; 22:767-8. [PMID: 23337262 DOI: 10.1016/j.hlc.2012.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/04/2012] [Indexed: 11/23/2022]
Abstract
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.
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The novel two-dimensional strain reflects improvement and remodeling of left-ventricular function better than conventional echocardiographic parameters after aortic valve repair in pediatric patients. Pediatr Cardiol 2013; 34:30-8. [PMID: 22660481 DOI: 10.1007/s00246-012-0376-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
Abstract
We aimed to evaluate the outcome and regional and global left-ventricular (LV) function after aortic valve repair in children with congenital aortic valve disease. Thirty-two consecutive patients with a mean age of 12.62 years (4 months to 18 years) undergoing aortic valve repair due to valve stenosis (AS group, n = 21) or aortic regurgitation (AR group, n = 11) were studied during a follow-up period of 12 months regarding change and adaptation of myocardial function using conventional and novel echocardiographic methods, including two-dimensional (2D) strain echocardiogram. Conventional and 2D strain echocardiographic studies were performed and analyzed off-line using commercially available software (EchoPac 6.1.0, GE). Peak aortic valve gradient decreased from 62.04 ± 30.34 mmHg before surgery to 22.80 ± 14.13 mmHg 2 weeks after surgery and to 35.73 ± 22.11 mmHg 12 months after surgery (p = 0.01). The degree of AR decreased significantly to grade 0 in 20 children and to grade I in 12. There was a significant decrease of thickness of the interventricular septum (IVS) and posterior wall resulting in improvement of LV mass index (p = 0.007, p = 0.043, and p = 0.001, respectively). Significant decrease of myocardial thickness was found, especially in the IVS, in the AS group (p = 0.008), and a significant decrease in LV end-diastolic dimension (EDD) was found in the AR group (p = 0.007). 2D strain analysis showed that global peak strain, global systolic strain rate, and global early diastolic strain rates improved significantly for all patients during the study period after aortic valve repair (p < 0.001, p = 0.037, and p = 0.018, respectively). The global strain and strain rates correlated significantly to IVS thickness (r = 0.002 and r = 0.003, respectively), LV mass index (r = 0.02 and r = 0.015, respectively), and EDD (r = 0.26 and r = 0.005, respectively). Aortic valve repair surgery in pediatric patients results in improvement of global and regional systolic and diastolic LV parameters, which was better shown by 2D strain parameters rather than conventional echocardiographic parameters.
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Elder RW, Quaegebeur JM, Bacha EA, Chen JM, Bourlon F, Williams IA. Outcomes of the infant Ross procedure for congenital aortic stenosis followed into adolescence. J Thorac Cardiovasc Surg 2012; 145:1504-11. [PMID: 23062969 DOI: 10.1016/j.jtcvs.2012.09.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 07/24/2012] [Accepted: 09/12/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The Ross procedure is used to treat aortic valve disease in children. The advantages include autograft growth, long-term durability, and avoidance of anticoagulation. Long-term follow-up of the Ross procedure in infancy is limited. We sought to characterize the long-term outcomes of infants undergoing the Ross procedure. METHODS We performed a retrospective review of all patients who underwent a Ross operation at 18 months of age or younger at New-York Presbyterian and Cardiothoracic Center of Monaco from 1991 to 2010. The clinical, catheterization, and surgical records were reviewed. The most recent follow-up information, including echocardiogram and electrocardiogram, was obtained and analyzed. RESULTS A total of 34 patients underwent a Ross procedure at a median age of 6 months (range, 4 days to 18.4 months). All had congenital aortic stenosis. All but 1 patient had undergone previous surgical or catheter-based interventions. The median follow-up was 10.6 years (range, 1.4-20.4 years). There were 4 early deaths and 1 late transplant. The freedom from right ventricular outflow tract reintervention was 85% at 5 years and 64% at 10 years. The freedom from autograft reintervention was 95.5% at 10 years. In 20 subjects, late follow-up echocardiograms showed a significant difference between the mean early and late Z scores of the autograft annulus (0.8 vs 2.4, P = .03), sinus (0.8 vs 2.8, P = .002), and sinotubular junction (1.2 vs 2.7, P = .04). Mild or less aortic insufficiency occurred in 17 subjects. None had significant aortic stenosis. CONCLUSIONS The long-term outcomes of the Ross procedure in infants and toddlers are favorable despite moderate dilatation of the autograft. Reintervention at the right ventricular outflow tract is common.
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Affiliation(s)
- Robert W Elder
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032-3784, USA.
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Maeda K, Rizal RE, Lavrsen M, Malhotra SP, Akram SA, Davies R, Suleman S, Reinhartz O, Murphy DJ, Hanley FL, Reddy VM. Midterm results of the modified Ross/Konno procedure in neonates and infants. Ann Thorac Surg 2012; 94:156-62; discussion 162-3. [PMID: 22626750 DOI: 10.1016/j.athoracsur.2012.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 02/27/2012] [Accepted: 03/01/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND The management of congenital aortic stenosis in neonates and infants continues to be a surgical challenge. We have performed the modified Ross-Konno procedure for patients who have severe aortic insufficiency or significant residual stenosis after balloon aortic dilation. The midterm results of this procedure were evaluated in this subset of patients. METHODS Between 1994 and 2010, a total of 24 patients younger than 1 year of age underwent the modified Ross-Konno procedure. The diagnoses were aortic stenosis with or without subaortic stenosis (n = 16), Shone's complex (n = 7), and interrupted aortic arch with subaortic stenosis (n = 1). The aortic root was replaced with a pulmonary autograft, and the left ventricular outflow tract (LVOT) was enlarged with a right ventricular infundibular free wall muscular extension harvested with the autograft. RESULTS Age at operation ranged from 1 to 236 days (median 28 days). The median follow-up period was 81 months (range 1-173 months). There was 1 early death and no late mortality. Overall the 1-, 2-, and 5-year survival rate was 95% ± 4.5%. Freedom from aortic stenosis was 94.7% ± 5.1% at 1, 2, and 5 years. Less than mild aortic insufficiency was 93.3% ± 6.4% at 2 years, and 74.7% ± 12.9% at 5 years. In total, 23 reoperations and reinterventions were performed; 14 were allograft conduit replacements. Two patients required aortic valve plasty. None required valve replacement. The reintervention-free rate was 64.6% ± 10.8% at 2 years and 36.9% ± 11.3% at 5 years. CONCLUSIONS Pulmonary autografts demonstrated good durability with low mortality and morbidity. This study shows that the modified Ross-Konno procedure can be a practical choice in selective cases for complex LVOT stenosis in neonates and infants.
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Affiliation(s)
- Katsuhide Maeda
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, California.
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Baird CW, Myers PO, del Nido PJ. Aortic valve reconstruction in the young infants and children. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2012; 15:9-19. [PMID: 22424502 DOI: 10.1053/j.pcsu.2012.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Considering the structure and function of the aortic root, changes in the aortic valve leaflets and changes in the geometry of the aortic root are the two primary causes of aortic valve dysfunction. In adults, aortic valve sparing reconstruction has a long history beginning in the 1970s, where tensor fascia was used for leaflet repair in patients with isolated aortic regurgitation and ascending aortic replacement was used in patients with ascending aortic aneurysms or aortic ectasia. Subsequent progress in the 1980s and 1990s led to pericardial leaflet replacement and aortic root re-implantation and remodeling. However, it has not been until the last decade that these concepts and techniques have been applied in younger patients focusing on the conotruncus, valvar apparatus, sino-tubular junction, and ascending aorta.
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Polimenakos AC, Sathanandam S, Blair C, Elzein C, Roberson D, Ilbawi MN. Selective tricuspidization and aortic cusp extension valvuloplasty: outcome analysis in infants and children. Ann Thorac Surg 2010; 90:839-46; discussion 846-7. [PMID: 20732505 DOI: 10.1016/j.athoracsur.2010.05.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 05/13/2010] [Accepted: 05/17/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Encouraging early outcomes of emerging aortic cusp extension valvuloplasty techniques have redirected attention to nonreplacement strategies in the management of younger patients with aortic insufficiency or aortic stenosis. Outcome analysis after aortic cusp extension valvuloplasty in infants and children was undertaken. METHODS From July 1987 to December 2008, 78 patients younger than 10 years of age underwent aortic cusp extension valvuloplasty in the form of pericardial cusp extension and selective use of tricuspidization. Sixteen (20.5%) patients were younger than 1 year of age. Twenty-seven had bicuspid aortic valve, 34, congenital aortic valve stenosis, and 17, congenital or acquired aortic insufficiency or aortic stenosis. Forty-two patients had balloon valvuloplasty or surgical valvotomy before aortic cusp extension valvuloplasty. Median follow-up was 12.4 years (range, 0.1 to 21.6 years). Freedom from aortic valve replacement (AVR) and determinants of outcome were analyzed. RESULTS There were no early or late deaths. During the follow-up period, 23 patients (29.5%) had Ross operation and 8 patients (10.2%) had other AVR. The z values of left ventricular end-diastolic dimension, aortic annulus, aortic sinus diameter, sinotubular junction diameter, and left ventricular wall thickness before AVR were 3.8 +/- 2.95, 2.1 +/- 1.15, 4.2 +/- 1.22, 1.78 +/- 1.24, and 2.92 +/- 1.31, respectively. Actuarial freedom from AVR at 1, 5, and 10 years was 97.3 +/- 2.0%, 71.3 +/- 5.8%, and 55.6 +/- 6.9%, respectively. CONCLUSIONS Aortic cusp extension valvuloplasty with tricuspidization allows left ventricular reverse remodeling with satisfactory long-term durability and freedom from AVR. Used selectively, it represents a reliable and effective approach in infants and children with congenital or acquired abnormal aortic valve.
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Affiliation(s)
- Anastasios C Polimenakos
- Division of Pediatric Cardiovascular Surgery, The Heart Institute for Children at Advocate Hope Children's Hospital, Oak Lawn, Illinois, USA.
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Van Dyck MJ, Watremez C, Boodhwani M, Vanoverschelde JL, El Khoury G. Transesophageal Echocardiographic Evaluation During Aortic Valve Repair Surgery. Anesth Analg 2010; 111:59-70. [DOI: 10.1213/ane.0b013e3181dd2579] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Intermediate-Term Results of the Ross Procedure in Neonates and Infants. Ann Thorac Surg 2010; 89:1827-32; discussion 1832. [DOI: 10.1016/j.athoracsur.2010.02.107] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 02/17/2010] [Accepted: 02/22/2010] [Indexed: 11/21/2022]
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Polimenakos AC, Sathanandam S, Elzein C, Barth MJ, Higgins RSD, Ilbawi MN. Aortic cusp extension valvuloplasty with or without tricuspidization in children and adolescents: long-term results and freedom from aortic valve replacement. J Thorac Cardiovasc Surg 2010; 139:933-41; discussion 941. [PMID: 20304137 DOI: 10.1016/j.jtcvs.2009.12.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Revised: 11/12/2009] [Accepted: 12/13/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Aortic cusp extension valvuloplasty is increasingly used in the management of children and adolescents with aortic stenosis or regurgitation. The durability of this approach and the freedom from valve replacement are not well defined. A study was undertaken to investigate outcomes. METHODS From July 1987 to November 2008, 142 patients aged less than 19 years underwent aortic cusp extension valvuloplasty in the form of pericardial cusp extension and tricuspidization (when needed). Three patients with truncus arteriosus and severe truncal valve insufficiency were excluded. From the available follow-up data of 139 patients, 50 had bicuspid aortic valves, 40 had congenital aortic valve stenosis, 41 had combined congenital aortic valve stenosis/insufficiency, and 8 had other diagnoses. Median follow-up was 14.4 years (0.1-21.4). Long-term mortality and freedom from aortic valve replacement were studied. RESULTS There were no early, intermediate, or late deaths. Z-values of left ventricular end-diastolic dimension, aortic annulus, aortic sinus diameter, and sinotubular junction diameter before aortic valve replacement were 4.2 +/- 3.11, 2.3 +/- 1.25, 4.4 +/- 1.23, and 1.84 +/- 1.28, respectively. During the follow-up period, 64 patients underwent aortic valve reinterventions. The Ross procedure was performed in 32 of 139 patients (23%) undergoing aortic cusp extension valvuloplasty. Other aortic valve replacements were undertaken after 16 aortic cusp extension valvuloplasties (11.5%). Freedom from a second aortic cusp extension valvuloplasty or aortic valve replacement at 18 years was 82.1% +/- 4.2% and 60.0% +/- 7.2%, respectively. CONCLUSION Aortic cusp extension valvuloplasty is a safe and effective surgical option with excellent survival and good long-term outcomes in children and adolescents. The procedure provides acceptable durability and satisfactory freedom from aortic valve replacement.
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Affiliation(s)
- Anastasios C Polimenakos
- Division of Pediatric Cardiovascular Surgery, Section of Cardiac Surgery, Department of Surgery, The Heart Institute for Children at Advocate Hope Children's Hospital, Oak Lawn, IL, USA.
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Pozzi M, Quarti A, Colaneri M, Oggianu A, Baldinelli A, Colonna PL. Valve repair in congenital aortic valve abnormalities☆. Interact Cardiovasc Thorac Surg 2010; 10:587-91. [DOI: 10.1510/icvts.2009.224097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Mechanical valves versus the Ross procedure for aortic valve replacement in children: Propensity-adjusted comparison of long-term outcomes. J Thorac Cardiovasc Surg 2009; 137:362-370.e9. [DOI: 10.1016/j.jtcvs.2008.10.010] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Revised: 09/09/2008] [Accepted: 10/09/2008] [Indexed: 11/19/2022]
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Morales DL, Carberry KE, Balentine C, Heinle JS, McKenzie ED, Fraser Jr CD. Selective Application of the Pediatric Ross Procedure Minimizes Autograft Failure. CONGENIT HEART DIS 2008; 3:404-10. [DOI: 10.1111/j.1747-0803.2008.00221.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bacha EA, McElhinney DB, Guleserian KJ, Colan SD, Jonas RA, del Nido PJ, Marx GR. Surgical aortic valvuloplasty in children and adolescents with aortic regurgitation: Acute and intermediate effects on aortic valve function and left ventricular dimensions. J Thorac Cardiovasc Surg 2008; 135:552-9, 559.e1-3. [DOI: 10.1016/j.jtcvs.2007.09.057] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 09/11/2007] [Accepted: 09/26/2007] [Indexed: 11/29/2022]
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Hawkins JA, Kouretas PC, Holubkov R, Williams RV, Tani LY, Su JT, Lambert LM, Mart CR, Puchalski MD, Minich LL. Intermediate-term results of repair for aortic, neoaortic, and truncal valve insufficiency in children. J Thorac Cardiovasc Surg 2007; 133:1311-7. [PMID: 17467448 DOI: 10.1016/j.jtcvs.2006.11.051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 10/31/2006] [Accepted: 11/06/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Repair of aortic valve insufficiency is difficult, and durability is relatively unknown in children. This study evaluates the intermediate-term results of repair of the systemic semilunar valve, including the native aortic valve, neoaortic valve (anatomic pulmonary), and truncal valve. METHODS We reviewed the records of 54 children (aged 2 days to 18 years) who underwent repair of the functional aortic valve for moderate or greater insufficiency from 1991 to 2005. Valve anatomy was tricuspid aortic in 26 patients, bicuspid aortic in 11 patients, tricuspid neoaortic in 9 patients, bicuspid neoaortic in 1 patient, and truncal valve in 7 patients. Multiple surgical techniques were used in most of the 54 patients, including leaflet plication in 17, leaflet repair in 15, commissuroplasty in 32, pericardial cusp augmentation in 8, and sinus of Valsalva reduction in 3. RESULTS There was 1 early death and no late deaths. Actuarial freedom from reoperation was 68% at 5 years and 58% at 10 years. Freedom from aortic valve replacement was 82% at 5 years and 73% at 10 years. Duration of cardiopulmonary bypass was the most significant risk factor for reoperation with multivariate analysis. Of the 40 patients who have not undergone reoperation, 37 have had follow-up echocardiograms with the latest study (4.5 +/- 4.2 years) demonstrating trace to 1+ insufficiency in 23 patients, 1 to 2+ in 12 patients, 2 to 3+ in 1 patient, and 3 to 4+ in 1 patient. CONCLUSION Repair of the insufficient systemic semilunar valve offers acceptable 10-year freedom from reoperation and functional results, and should be considered for most children.
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Affiliation(s)
- John A Hawkins
- Division of Cardiothoracic Surgery, Department of Surgery, Primary Children's Medical Center, and the University of Utah, Salt Lake City, Utah 84113, USA.
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Hraska V, Photiadis J, Arenz C. Open valvotomy for aortic valve stenosis in newborns and infants. Multimed Man Cardiothorac Surg 2007; 2007:mmcts.2006.002311. [PMID: 24414321 DOI: 10.1510/mmcts.2006.002311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The most appropriate management of aortic stenosis in children remains controversial. Both balloon and surgical valvotomy are firmly established as effective initial treatments with encouraging survival rates even in the troublesome neonatal group. Improved early results are based rather on the better understanding of the limits of a biventricular repair than on the method of treatment. Valvotomy of any kind is a palliative procedure and reintervention remains frequent. Direct surgical intervention, where exact splitting of fused commissures and shaving off of obstructing nodules can produce a better valve with maximum valve orifice without causing regurgitation, might offer superior longer-lasting results in comparison with blind ballooning.
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Affiliation(s)
- Viktor Hraska
- Department of Pediatric Cardiac Surgery, German Pediatric Heart Center, Asklepios Clinic Sankt Augustin, Arnold Jansen Str. 29, 53757 Sankt Augustin, Germany
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Dave H, Prêtre R. Pericardial patch reconstruction of the congenitally diseased aortic valve. Multimed Man Cardiothorac Surg 2007; 2007:mmcts.2005.001354. [PMID: 24414200 DOI: 10.1510/mmcts.2005.001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Congenital aortic valve disease manifests itself either in the course of its natural history or as a consequence of an intervention (balloon dilatation or surgery). In infancy, a congenital aortic valve presents with stenosis, in childhood and adolescence as slowly evolving regurgitation after primary intervention/surgery and in late adulthood, they re-emerge as stenosis due to natural degeneration and calcification of the fused leaflets. The surgical approach to a congenital aortic valve disease differs depending on whether it is a malformed or a normally laid down (tri-sinusoidal tricuspid) valve; it also differs depending on the type of deformity, dysfunction and valve tissue presenting at surgery. Acutely regurgitant aortic valve in a neonate or an infant after balloon dilatation of congenital aortic stenosis is an infrequently occurring difficult problem with few available options. This video presentation demonstrates a xenopericardial patch repair of the torn fused leaflet (fusion between the right and the noncoronary cusp) of a congenitally stenotic valve, followed by height augmentation of all the three leaflets. Because of the relative hypoplasia of the aortic annulus and the ascending aorta, the aortic root and proximal ascending aorta were enlarged by an oblong xenopericardial patch. The following text includes additional technical issues involved in congenital aortic valve repair. A brief summary of literature is presented.
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Affiliation(s)
- Hitendu Dave
- Division of Congenital Cardiovascular Surgery, University Hospital and University Children's Hospital, Steinwiesstrasse 75, CH-8032, Zurich, Switzerland
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Honjo O, Kotani Y, Osaki S, Fujita Y, Suezawa T, Tateishi A, Ishino K, Kawada M, Akagi T, Sano S. Discrepancy Between Intraoperative Transesophageal Echocardiography and Postoperative Transthoracic Echocardiography in Assessing Congenital Valve Surgery. Ann Thorac Surg 2006; 82:2240-6. [PMID: 17126141 DOI: 10.1016/j.athoracsur.2006.06.073] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Revised: 06/15/2006] [Accepted: 06/19/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the discrepancy between intraoperative transesophageal and postoperative transthoracic echocardiography in assessing residual regurgitation in children undergoing valve repair. METHODS Forty-two consecutive children (median age, 5.1 years) who underwent valve repair for valvar regurgitation from 2001 to 2004 were retrospectively analyzed. The patients were divided into two groups: atrioventricular valve group (n = 33) and aortic valve group (n = 9). Regurgitation grade, fractional shortening, and atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography were compared with those obtained by transthoracic echocardiography at discharge (median, 11 days) and at follow-up (median, 8 months). RESULTS Intraoperative transesophageal echocardiography revealed specific residual lesions in 4 patients, leading to successful re-repair. Fractional shortening obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the atrioventricular valve group, the regurgitation grade obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (0.7 +/- 0.8 versus 1.4 +/- 0.9; p < 0.01), and agreement between the two examinations was found in 12 patients (38%). Peak atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the aortic valve group, there was no significant difference between the regurgitation grades in the two examinations (0.8 +/- 0.8 versus 1.1 +/- 0.9), and complete agreement in regurgitation grade was found in 5 (56%) of 9 patients. CONCLUSIONS There were considerable discrepancies between the examinations in evaluation of residual atrioventricular valve regurgitation and potential atrioventricular valve stenosis: most of the residual regurgitations were underestimated by intraoperative transesophageal echocardiography. In contrast, reasonable agreement was found between the two examinations in evaluation of aortic valve regurgitation.
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Affiliation(s)
- Osami Honjo
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
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Gleason TG. Current Perspective on Aortic Valve Repair and Valve-Sparing Aortic Root Replacement. Semin Thorac Cardiovasc Surg 2006; 18:154-64. [PMID: 17157237 DOI: 10.1053/j.semtcvs.2006.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2006] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Thomas G Gleason
- Thoracic Aortic Surgery Program, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-3056, USA.
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