Issues and outcomes in the management of supravalvar aortic stenosis

Long-term surgical outcomes of congenital supravalvular aortic stenosis: a systematic review, meta-analysis and microsimulation study

OBJECTIVES

Congenital supravalvular aortic stenosis (SVAS) is a rare form of congenital outflow tract obstruction and long-term outcomes are scarcely reported. This study aims to provide an overview of outcomes after surgical repair for congenital SVAS.

METHODS

A systematic review of published literature was conducted, including observational studies reporting long-term clinical outcome (>2 years) after SVAS repair in children or adults considering >20 patients. Early risks, late event rates and time-to-event data were pooled and entered into a microsimulation model to estimate 30-year outcomes. Life expectancy was compared to the age-, sex- and origin-matched general population.

RESULTS

Twenty-three publications were included, encompassing a total of 1472 patients (13 125 patient-years; pooled mean follow-up: 9.0 (6.2) years; median follow-up: 6.3 years). Pooled mean age at surgical repair was 4.7 (5.8) years and the most commonly used surgical technique was the single-patch repair (43.6%). Pooled early mortality was 4.2% (95% confidence interval: 3.2-5.5%) and late mortality was 0.61% (95% CI: 0.45-0.83) per patient-year. Based on microsimulation, over a 30-year time horizon, it was estimated that an average patient with SVAS repair (mean age: 4.7 years) had an observed life expectancy that was 90.7% (95% credible interval: 90.0-91.6%) of expected life expectancy in the matched general population. The microsimulation-based 30-year risk of myocardial infarction was 8.1% (95% credible interval: 7.3-9.9%) and reintervention 31.3% (95% credible interval: 29.6-33.4%), of which 27.2% (95% credible interval: 25.8-29.1) due to repair dysfunction.

CONCLUSIONS

After surgical repair for SVAS, 30-year survival is lower than the matched-general-population survival and the lifetime risk of reintervention is considerable. Therefore, lifelong monitoring of the cardiovascular system and in particular residual stenosis and coronary obstruction is recommended.

Human Genetics of Semilunar Valve and Aortic Arch Anomalies

Lesions of the semilunar valve and the aortic arch can occur either in isolation or as part of well-described clinical syndromes. The polygenic cause of calcific aortic valve disease will be discussed including the key role of NOTCH1 mutations. In addition, the complex trait of bicuspid aortic valve disease will be outlined, both in sporadic/familial cases and in the context of associated syndromes, such as Alagille, Williams, and Kabuki syndromes. Aortic arch abnormalities particularly coarctation of the aorta and interrupted aortic arch, including their association with syndromes such as Turner and 22q11 deletion, respectively, are also discussed. Finally, the genetic basis of congenital pulmonary valve stenosis is summarized, with particular note to Ras-/mitogen-activated protein kinase (Ras/MAPK) pathway syndromes and other less common associations, such as Holt-Oram syndrome.

Computed Tomographic Evaluation of Congenital Left Ventricular Outflow Obstruction

Congenital left ventricular outflow obstruction represents a multilevel obstruction with several morphological forms. It can involve the subvalvular, valvar, or supravalvular portion of the aortic valve complex, and may coexist. Computed tomography (CT) plays an important supplementary role in the evaluation of patients with congenital LVOT obstruction. Unlike transthoracic echocardiography and cardiovascular magnetic resonance (CMR) imaging, it is not bounded by a small acoustic window, needs for anaesthesia or sedation, and metallic devices. Current generations of CT scanners with excellent spatial and temporal resolution, high pitch scanning, wide detector system, dose reduction algorithms, and advanced 3-dimensional postprocessing techniques provide a high-quality alternative to CMR or diagnostic cardiac catheterization. Radiologists performing CT in young children should be familiar with the advantages and disadvantages of CT and with the typical morphological imaging features of congenital left ventricular outflow obstruction.

Supravalvar aortic stenosis: Imaging characteristics and associations on multidetector computed tomography angiography

AIM

To evaluate the imaging features and associations in patients with supravalvar aortic stenosis on multidetector computed tomography (CT) angiography.

MATERIALS AND METHODS

We retrospectively reviewed all CT angiography studies performed for evaluation of congenital heart diseases at our institution through the period from January 2014 to June 2020. Cases with supravalvar aortic stenosis were identified and classified as syndromic and nonsyndromic based on history, physical examination, and relevant investigations. The type and extent of vascular involvement and associated cardiovascular abnormalities were characterized.

RESULTS

Supravalvar aortic stenosis was identified in 26/3926 (0.66%) patients (22 males and 4 females; Age range: 2 months to 20 years). Discrete stenosis was seen in 14/26 (53.8%) patients, while diffuse involvement of the ascending aorta to varying degrees was seen in the remaining 12 (46.2%) patients. About 15/26 (57.7%) patients had pulmonary involvement at some level, namely, infundibular, valvar, supravalvar, or peripheral pulmonic stenosis while 15/26 (57.7%) patients had coronary arterial involvement either in the form of stenosis, occlusion, or ectasia. Aortic valvular abnormality including thickening, partial fusion, and adhesion of leaflet edges to the sinutubular junction causing reduced coronary inflow was seen in 15/26 (57.7%) patients. Associated ventricular septal defect, patent ductus arteriosus, and mitral valvular prolapse were seen in four (15.4%), five (19.2%), and two (7.7%) patients respectively.

CONCLUSION

Supravalvar aortic stenosis is a rare abnormality showing associated pulmonary arterial involvement, coronary arterial involvement, aortic valvular abnormalities, and associated congenital cardiac defects in the majority of cases, which may influence surgical outcomes.

Clinical history and management of bicuspid aortic valve in children and adolescents

Bicuspid aortic valve (BAV) is one of the most common congenital heart defects in children, adolescents and adults. BAV can occur as an isolated lesion or in association with other congenital heart defects, such as coarctation of the aorta or genetic syndromes like Turner syndrome. Although the majority of long term complications associated with BAV manifest later in life, children and adolescents may present with early onset valvular dysfunction or dilation of the aorta. BAV is a heterogeneous disease with a wide array of presentations at various ages, depending on the degree of aortic valve dysfunction, aortic dilation and presence of associated lesions. Aortic valve stenosis and/or regurgitation are the primary indications for intervention in children and adolescents with BAV. Although a majority of young patients with BAV also have some aortic dilation, interventions on the aorta are very rare during this time frame. Children and adolescents with BAV benefit from comprehensive assessment of their risk profile to determine follow-up surveillance intervals, sports recommendations, and timing of surgical intervention. The morphologic phenotype of BAV is important to identify, as it may predict future complications and prognosis.

Proposed method for evaluation and categorization of functional capacity of children, adolescents, and adults with cardiac diseases to bring them in existing social justice system by creating the cardiac disability criteria

INTRODUCTION

Emerging epidemiological trends in India indicate the rising burden of cardiovascular diseases (CVDs) demanding a need of a social support system. Yet, the list of 21 benchmark disabilities notified by the Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India, does not include CVDs under the newly enacted Rights of Persons with Disabilities (RPWD) Act, 2016. While the RPWD Act 2016 has acknowledged the dynamic nature of disabilities associated with congenital diseases like thalassemia, it has also provided an opportunity to bring in "cardiac disability" under its tenets. This would allow India to adopt strategies for the benefit of cardiac patients in accordance with policies adopted by developed countries such as the United States of America (USA), the United Kingdom of Great Britain (UK), and Canada. This document is to initiate a thought process of recruitment of cardiac patients in the social justice system.

AIMS AND OBJECTIVES

(1) To define cardiac disability, (2) to categorize cardiac diseases/defects (groups A-C) according to severity and need for interventions, (3) to identify operated and unoperated patients with normal functional capacity and their eligibility to avail normal opportunities similar to their peer groups, (4) to create a comprehensive cardiac disability scoring (CCDS) system for disability certification based on subjective and objective evaluation of functional capacity and the corresponding heart disease category group, and (5) to create a reference literature for the issues of education, employability, insurability, and vocational counseling based on this document.

METHODOLOGY

The evolution of this manuscript has been discussed in view of relevant observations made by a team of cardiologists, cardiac surgeons, intensivists, pediatricians, social workers, etc.

CONCLUSION

This manuscript suggests a CCDS system to lay down criteria for disability status for eligible patients suffering from cardiovascular diseases. It intends to offer a unique scientific tool to address the psychosocial and socio-economic bias against patients with heart diseases of heterogeneous nature.

Avoidance of malignant arrhythmia caused by displacement of the right coronary artery ostium in surgical correction of supravalvular aortic stenosis

Objective

This study was performed to identify the effects of different surgical approaches on the right coronary artery ostium in patients with congenital supravalvular aortic stenosis (SVAS) and to determine how to avoid surgically induced right coronary artery occlusion.

Methods

The surgical techniques and outcomes of 91 patients who underwent surgical treatment of SVAS from 2008 to 2015 in our institution were retrospectively reviewed to identify the causes of early death, reoperation, and extracorporeal membrane oxygenation (ECMO) support.

Results

Four perioperative deaths (Doty’s technique, n = 4), six cases of ECMO support (Doty’s technique, n = 4; Brom’s technique, n = 1; McGoon’s technique, n = 1), and eight reoperations (Doty’s technique, n = 5; Brom’s technique, n = 2; McGoon’s technique, n = 1) occurred. In cases of reoperation, adjustment of the shape and position of the right coronary sinus patch relieved the malignant arrhythmia.

Conclusion

Different surgical techniques have different effects on the right coronary artery. The shape of the patch inserted into the right coronary sinus should be carefully clipped to avoid distortion and ischemia of the right coronary artery.

EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: Congenital left-sided heart obstruction

Congenital obstruction of the left ventricular outflow tract remains a significant problem and multilevel obstruction can often coexist. Obstruction can take several morphological forms and may involve the subvalvar, valvar or supravalvar portion of the aortic valve complex. Congenital valvar stenosis presenting in the neonatal period represents a spectrum of disorders ranging from the hypoplastic left heart syndrome to almost normal hearts. Treatment options vary dependent on the severity of the left ventricular outflow tract obstruction (LVOTO) and the variable degree of left ventricular hypoplasia as well as the associated lesions such as arch hypoplasia and coarctation.

Supravalvar aortic stenosis: current surgical approaches and outcomes

Supravalvar aortic stenosis (SVAS) is a congenital anomaly characterized by a discrete or diffuse narrowing of the ascending aorta. It may also be associated with right-ventricular outflow tract obstruction, aortic valve pathology and coronary ostial stenosis. While present in both familial and sporadic forms, it demonstrates a strong association with William-Beuren syndrome, both being anomalies associated with defects in the elastin gene. In this article, the authors have discussed the etiology, morphology, clinical presentation and genetic basis of SVAS. Various surgical approaches, both conventional and recent, have been discussed and demonstrated with the aid of diagrams. Single-, two- and three-sinus methods have been presented, along with a comparative analysis of early results, associated procedures, late mortality and reoperation. In conclusion, the authors have described their institutional experience of more than 40 years in the surgical management of SVAS.

Outcome of surgical correction of congenital supravalvular aortic stenosis with two- and three-sinus reconstruction techniques

BACKGROUND

Several surgical techniques for the treatment of congenital supravalvular aortic stenosis have been developed, yet there is no consensus about the optimal approach. We reviewed our institutional experience with 2- and 3-sinus reconstruction techniques.

METHODS

Thirty-eight patients operated on for supravalvular aortic stenosis between 1987 and 2012 in our institution were analyzed retrospectively. Eight patients (21%) were infants and in 5 (13.2%) diffuse stenosis was present. Mean peak pressure gradient was 86.1±28.7 mm Hg preoperatively. Surgical procedures included single-patch enlargement (McGoon, n=3), inverted bifurcated-patch aortoplasty (Doty, n=22), 3-sinus patch augmentation (Brom, n=8), and autologous slide aortoplasty (n=5). Major concomitant procedures were performed in 10 patients (26.3%).

RESULTS

Early mortality was 2.6%. Follow-up continued for a median of 7.5 years (range 3 weeks to 22 years). Overall survival estimates were 94% and 90% and overall freedom from reoperation was 83% at 5 and 20 years, respectively. No differences were found between surgical techniques in respect to survival, clinical course, hemodynamic outcome, or freedom from reoperation rates. A significantly worse outcome in regard to survival and reoperation rates was observed in infants.

CONCLUSIONS

Our study demonstrates equally good results for the repair of supravalvular aortic stenosis with both 2- and 3-sinus reconstruction. No evidence of a superior outcome for 3-sinus reconstruction techniques was found. Operation in infancy is an important factor associated with unfavorable outcome.

Cardiovascular manifestations of Williams syndrome: imaging findings

Williams syndrome is a relatively common (1 in 10,000 live births) genetic disorder caused by a deletion involving chromosome 7 that results in a variety of clinically significant abnormalities, including developmental delay, behavioral changes, hypercalcemia, and a distinct "elfin" facial appearance. Congenital cardiovascular disease that presents in childhood is responsible for most of the morbidity and mortality associated with this disorder. The purpose of this pictorial essay is to review imaging findings of some of the more common cardiovascular manifestations of Williams syndrome and to highlight some of the unique anatomic variations that can be seen in these patients.

Outcomes After Primary Transcatheter Therapy in Infants and Young Children With Severe Bilateral Peripheral Pulmonary Artery Stenosis

Background—

Angioplasty and stent implantation have become accepted therapies for isolated peripheral pulmonary stenosis, and have been shown to increase vessel diameter and reduce right ventricular (RV) pressure acutely in patients with pulmonary artery (PA) stenosis. The purpose of this study was to assess long-term outcomes after primary transcatheter therapy for peripheral pulmonary stenosis.

Methods and Results—

We studied 69 patients who underwent primary transcatheter intervention for severe isolated peripheral pulmonary stenosis at ≤5 years of age. Genetic/syndromic diagnoses included Williams syndrome (n=23), non-Williams familial arteriopathy (n=12), and Alagille syndrome (n=3). At the initial PA intervention, median RV:aortic pressure ratio decreased from 1.00 to 0.88 (median decrease, 0.18; P <0.001). Patients with a higher preintervention RV:aortic pressure ratio had a greater reduction ( P <0.001). During follow-up (median, 8.5 years), 10 patients died, 5 from complications of PA catheterization (all before 1998). Thirteen patients underwent surgical PA intervention, most within 1 year and along with repair of supravalvar aortic stenosis. Freedom from any PA reintervention was 38±6% at 1 year and 22±6% at 5 years. The median RV:aortic pressure ratio decreased from 1.0 at baseline to 0.53 at the most recent catheterization ( P <0.001), and 82% of patients with available clinical follow-up were asymptomatic.

Conclusions—

Transcatheter therapy for infants with severe peripheral pulmonary stenosis has become safer, regardless of genetic condition. Coupled with reintervention and surgical relief in selected cases, RV:aortic pressure ratios decrease substantially and most patients are asymptomatic at late follow-up.

Supravalvular aortic stenosis: elastin arteriopathy

Supravalvular aortic stenosis is a systemic elastin (ELN) arteriopathy that disproportionately affects the supravalvular aorta. ELN arteriopathy may be present in a nonsyndromic condition or in syndromic conditions such as Williams-Beuren syndrome. The anatomic findings include congenital narrowing of the lumen of the aorta and other arteries, such as branches of pulmonary or coronary arteries. Given the systemic nature of the disease, accurate evaluation is recommended to establish the degree and extent of vascular involvement and to plan appropriate interventions, which are indicated whenever hemodynamically significant stenoses occur. ELN arteriopathy is genetically heterogeneous and occurs as a consequence of haploinsufficiency of the ELN gene on chromosome 7q11.23, owing to either microdeletion of the entire chromosomal region or ELN point mutations. Interestingly, there is a prevalence of premature termination mutations resulting in null alleles among ELN point mutations. The identification of the genetic defect in patients with supravalvular aortic stenosis is essential for a definitive diagnosis, prognosis, and genetic counseling.

Pulmonary stenosis is a predictor of unfavorable outcome after surgery for supravalvular aortic stenosis

We sought to evaluate whether the presence of pulmonary stenosis (PS), amongst other factors, influences the mortality and the rate of reoperations in the long-term follow-up of patients with supravalvular aortic stenosis (SVAS). We identified all patients with SVAS from our surgical database. The patients with multi-level aortic stenosis or concomitant cardiac procedures were excluded from this study. Follow-up (100 %) was conducted between 2008 and 2010. Twenty-six patients underwent surgery for SVAS between 1974 and 2006. Seventeen patients (65 %) were diagnosed with Williams-Beuren-Syndrome, six (17 %) had a diffuse form of SVAS and 10 (39 %) had PS. No patient had a surgical or interventional procedure for PS at the initial operation or during follow-up. There was no statistically significant association between PS and WBS (p = 0.30) or diffuse form of SVAS (p = 0.13). Patients with PS were operated at younger age (p = 0.028). Median follow-up time was 14.6 years. Overall mortality was 11.5 %. One patient with preoperatively severely decreased LV-function died 27 days postoperatively. Two late deaths occurred 7 and 10 years after the initial operation. Reoperations were required in 4 patients (15 %), 4-19 years after the original operation, due to aortic arch stenosis, supravalvular restenosis or poststenotic aortic dilatation. PS was found to be a risk factor for reoperation (p = 0.005) and for the combined reoperation/death end-point (p = 0.003). PS in patients with SVAS is a risk factor for reoperations in the aortic region and might be considered an indicator of the severity of the arterial disease and a predictor of an unfavourable outcome.

Supravalvar aortic stenosis in infancy

Supravalvar aortic stenosis (SVAS) is a rare anomaly of the aortic root caused by a genetically based deficiency in elastin production. Concomitant primary and secondary cardiovascular lesions complicate surgical management and impact early and late outcomes. Because SVAS is a rare lesion, surgical series are relatively small and span lengthy time periods. Consequently, risk factors that influence early and late outcomes are not well defined. Patients who come to surgery during infancy are particularly challenging, but little attention has been directed as to whether or not young age influences outcomes. This review suggests that complicating associated features of elastin arteriopathy are more prevalent in patients who require relief of SVAS during infancy, and that concomitant lesions significantly increase the difficulty and risk of treating younger patients with SVAS.

Uncommon congenital and acquired aortic diseases: role of multidetector CT angiography

State-of-the-art multidetector computed tomographic (CT) technology has replaced invasive angiography for evaluation of patients suspected to have aortic disease. Although most aortic disease is associated with atherosclerosis (ie, aneurysms and dissection), the spectrum of aortic disease is vast and includes various congenital and acquired entities. Radiologists should also be familiar with uncommon aortic diseases, which are divided into those that are congenital in origin and acquired disorders, and with their findings at multidetector CT. The first group includes patent ductus arteriosus, aortic hypoplasia, aortic coarctation, interrupted aortic arch, aortopulmonary window, common arterial trunk, supravalvular aortic stenosis, and vascular rings. The acquired disorders include aortic dissection due to extension of a coronary artery dissection, Marfan syndrome, large-vessel vasculitis such as Takayasu arteritis, and mycotic aneurysms. Finally, specific conditions associated with therapeutic maneuvers--such as recoarctation, stent-graft rupture, and endoleaks--can also be assessed with multidetector CT. Multidetector CT is an alternative tool helpful in establishing the primary diagnosis, defining anatomic landmarks and their relationships, and identifying associated cardiovascular anomalies. It is also an adjunct in the evaluation of complications during follow-up.

Surgical management of supravalvular aortic stenosis: does Brom three-patch technique provide superior results?

BACKGROUND

Various surgical techniques have been proposed to repair supravalvular aortic stenosis. However, the optimal approach remains to be determined. The present study was undertaken to evaluate the results of surgery for supravalvular aortic stenosis and to compare the symmetric three-patch repair (Brom technique) with other surgical reconstructions.

METHODS

Between 1995 and 2007, 34 patients with supravalvular aortic stenosis underwent surgery. Fourteen patients (41%) had Williams syndrome. Supravalvular stenosis was discrete in 24 patients (71%) and diffuse in 10 (29%). Eight patients (23%) underwent one-patch repair; 3 patients (9%) had inverted bifurcated patch enlargement (Doty repair) and 23 patients (68%) had symmetric repair (Brom three-patch technique). Follow-up was complete and ranged from 6 months to 12 years (mean, 5.8 years).

RESULTS

There was one early and no late deaths. One patient (with one-patch repair) underwent reoperation for residual obstruction. At last follow-up, left ventricle to aorta peak gradient was 45 +/- 28 mm Hg after one-patch repair, 30 +/- 9 mm Hg after Doty operation, and 11 +/- 18 mm Hg after symmetric Brom procedure. Brom repair was associated with a low incidence of residual obstruction (peak gradient > or = 40 mm Hg) (2 of 22; 9.1%) and moderate aortic insufficiency (1 of 22; 4.5%).

CONCLUSIONS

Brom three-patch repair provides symmetric reconstruction of the aortic root in patients with supravalvular aortic stenosis. This may lead to improved midterm results in terms of relief of the obstruction and incidence of aortic insufficiency.

Supravalvular aortic stenosis of the diffuse type: 29 years follow-up after aortic endarterectomy and symmetric enlargement of the ascending aorta and of the three coronary sinuses

Supravalvular aortic stenosis is a rare congenital anomaly characterized by variable amounts of left ventricular outflow tract obstruction distal to the aortic valve. Macroscopically, it is categorized into three morphologic subtypes: membranous, hourglass, and diffuse. The diffuse type is the most rare, and its surgical repair is the most challenging due to variable length of ascending aorta hypoplasia. Surgical treatment options of supravalvular aortic stenosis are well established for the membranous and hourglass type, whereas they are challenging and less well defined for the diffuse type. We present a case of long-term follow-up (29 years) after a very complex surgical repair of supravalvular aortic stenosis of the diffuse type, with focus on technical aspects. To our knowledge, the present case represents one of the longest follow-up routines in the English language literature of surgical treatment of supravalvular aortic stenosis.

Applying heart failure guidelines to adult congenital heart disease patients

There is a growing population of adult patients with congenital heart defects in the developed world. Most have been repaired, but few have been cured. Many have myocardial dysfunction. Most have exercise intolerance. Some have heart failure. As a group, they show neurohormonal activation similar to that seen in an adult heart failure population with acquired heart disease. Currently, the patients at greatest risk of heart failure are those without a systemic left ventricle, such as Mustard and Senning repairs of transposition of the great arteries (TGA), congenitally corrected TGA, and patients who have had a Fontan procedure. Exercise intolerance may predict hospitalization and death in such patients. For those patients with systemic left ventricles, it would seem reasonable to use the heart failure guidelines developed for patients with acquired heart disease. For those patients without a systemic left ventricle (e.g., a systemic right ventricle or single ventricle), there is currently no foundation for evidence-based therapy.

Progressive diffuse aortic stenosis after localized supravalvular aortic stenosis repair

A 6-year-old boy presented with diffuse stenosis of the aortic arch. He had undergone patch augmentation for localized supravalvular aortic stenosis at 2 years of age. Before the initial operation, the aortic arch and descending aorta were noticed to be hypoplastic with a diameter of 60 to 73% of that of the aortic annulus, without a pressure gradient. 4 years later, progressive diffuse stenosis of the aortic arch with a diameter of 42% of that of the aortic annulus was found. Reoperation, consisting of patch augmentation of the aortic arch, was carried out. A pressure gradient of 40 mmHg distal to the repair was newly recognized, again. This is a rare case of supravalvular aortic stenosis, which required reoperation because of the progression of diffuse stenosis of the distal aorta.

Surgery for aortic stenosis in children: a 40-year experience

BACKGROUND

Aortic stenosis (AS) is encountered in approximately 5% of children with heart disease. The indications for surgery and the surgical techniques for AS are well established. This report focuses on the early and long-term outcomes in children with AS over a 40-year period.

METHODS

Included in this study were 508 patients ranging in ages from 1 day to 19 years, who were operated on for AS between 1960 and 2002. Eighty-one percent (414 of 508) of the patients had left ventricular outflow tract obstruction (LVOTO) at a single level: 40 supravalvar, 242 valvar (critical AS in 85 neonates and young infants and in 157 older children), and 132 subvalvar. Nineteen percent (94 of 508) of the patients had LVOTO at more than one level. Associated congenital cardiac defects were found in 32% of the patients.

RESULTS

The overall hospital mortality rate was 8% (40/508) with neonates with critical AS having the highest mortality (33%). The late mortality was 4% for the entire group. Follow-up was 95% complete. The mean follow-up was 8.5 +/- 7.1 years. In the subgroup with multilevel LVOTO (n = 94), the average intraoperative peak systolic left ventricular-aortic gradient decreased from 80 to 22 mm Hg after repair but increased progressively to 74 +/- 36 mm Hg (p < 0.05) before reintervention was required. One hundred twenty-one patients (24%) underwent 151 reoperations for recurrent or residual LVOTO or aortic regurgitation. Actuarial curves predict a 20-year survival of 88% and 62% freedom from reoperation for all patients with AS. Symptomatic improvement in survivors was excellent (90% New York Heart Association class I).

CONCLUSIONS

Surgical relief of LVOTO in infants and children can be accomplished with low mortality and morbidity. Neonates with critical AS have significantly higher mortality and morbidity due to their complex anatomy and their critical presentation that affects outcome. Aortic valvotomy delays valve replacement in a significant percentage of children. The Ross procedure and mechanical aortic valve replacements have had a low mortality and morbidity in our series. Valve replacement will eventually be required in most children presenting with valvar AS and multilevel LVOTO while repair of discrete subaortic stenosis and supravalvar AS may not require reoperation in most patients. Children with LVOTO should have lifetime follow-up.

[Congenital aortic supravalvular stenosis. Frequency and results of surgical treatment in a third level hospital]

In a prospective study made between 1 September 1996 and 31 December 2001, pediatric patients with a diagnosis of supravalvular aortic stenosis confirmed by a reduction in the aortic inner diameter and a gradient > or = 50 mmHg were detected. Of 83 patients with aortic stenosis, only 7 (8.4%) had supravalvular aortic stenosis. All 7 patients underwent surgical treatment consisting of resection of fibrous tissue and reconstruction of the ascending aorta with a preclotted Dacron patch. One patient with severe, diffuse stenosis died and the another had perioperative heart failure, cardiac arrest and reversible neurological sequelae. A significant decrease in the postoperative gradient was obtained (p < 0.05). At present all surviving patients are free of symptoms. It was concluded that supravalvular aortic stenosis is infrequent in Mexico. In our experience, surgical treatment produced good results and success depended on the magnitude and type of stenosis.

Congenital supravalvar aortic stenosis: a simple lesion?

The underlying cause of congenital supravalvular aortic stenosis (SVAS) has recently been identified as a loss-of function mutation of the elastin gene on chromosome 7q11.23, resulting in an obstructive arteriopathy of varying severity, which is most prominent at the aortic sinutubular junction. The generalized nature of the disease explains the frequent association with stenoses of systemic and pulmonary arteries. Furthermore, localization of the supravalvular stenosis at the level of the commissures of the aortic valve has important implications for both aortic valve function and coronary circulation. This review summarizes the recent advances with regard to the pathogenesis of SVAS and describes the multitude of clinically relevant pathologic features other that the mere 'supra-aortic' narrowing that have important implications for surgical therapy.

Surgical management of congenital obstruction of the left main coronary artery with supravalvular aortic stenosis

OBJECTIVE

Stenosis of the left main coronary artery is a recognized complicating feature of supravalvular aortic stenosis. We have retrospectively identified three anatomic subtypes of left main coronary obstruction in patients with supravalvular aortic stenosis, each necessitating a distinct surgical approach.

METHODS

From 1991 to 1998, 9 patients underwent surgical repair of supravalvular aortic stenosis and left main coronary stenosis. Five patients (group 1) had obstruction from near-circumferential thickening of the left main ostium, 2 patients (group 2) had restricted coronary flow due to fusion of an aortic valve leaflet to the supravalvular ridge, and 2 patients (group 3) had diffuse narrowing of the left main coronary artery. Group 1 patients were treated with patch aortoplasty encompassing the left main ostium and supravalvular aortic stenosis. Group 2 patients were treated with excision of the fused leaflet from the aortic wall and patch aortoplasty. Group 3 patients were treated with bypass grafting and aortoplasty.

RESULTS

Surgical strategy was determined by coronary angiography and intraoperative assessment of coronary anatomy. There was 1 early death. All surviving patients underwent echocardiography with or without postoperative catheterization. The mean postoperative supravalvular gradient for 7 patients was 8 mm Hg (range 2-15 mm Hg). One patient required reoperation for a residual aortic gradient as a result of aortic arch involvement. No evidence of left main coronary artery stenosis was seen in groups 1 and 2; bypass grafts were patent in group 3 patients at a mean follow-up of 54.8 months.

CONCLUSION

Three subtypes of left main coronary stenosis with supravalvular aortic stenosis are described. Each anatomic type mandates an individual surgical approach. Favorable surgical outcomes are achievable with each category.

Advances in pediatric cardiovascular surgery: anatomic reconstruction of the left ventricular outflow tract in transposition of the great arteries with pulmonic valve abnormalities

In the past years, advances in pediatric cardiovascular surgery have occurred in many areas with some of the greatest strides being made in complex repairs in younger age groups. Aggressive early corrections while higher risk, may in the long run provide a child with a normal anatomic heart, and corresponding myocardial growth and physiology.