Congenital Heart Surgery

Mortality and Reoperation Risk After Bioprosthetic Aortic Valve Replacement in Young Adults With Congenital Heart Disease. Fuller SM, Borisuk MJ, Sleeper LA, Bacha E, Burchill L, Guleserian K, Ilbawi M, Razzouk A, Shinkawa T, Lu M, Baird CW. Semin Thorac Cardiovasc Surg. 2021 Jun 24:S1043-0679(21)00301-4.   Take Home Points: Smaller valve size indexed to BSA is a risk for reoperation. Younger age, especially <21 years old is associated with more reoperation. Commentary by Dr. Yasuhiro Kotani, MD, PhD, Okayama, Japan Congenital Heart Surgery section editor Summary: Data were retrospectively collected for 314 patients undergoing bAVR at 8 centers from 2000-2014. Average age was 45.2 years (IQR 17.8-71.1) and 30% were <21. Indications were stenosis (48%), regurgitation (28%) and mixed (18%). Twenty-eight (9%) underwent prior AVR. Median valve size was 23mm (IQR 21, 25). Implanted valves included CE (Carpentier-Edwards) Perimount (47%), CE Magna/Magna Ease (29%), Sorin Mitroflow (9%), St Jude (2%) and other (13%). Median follow-up was 2.9 (IQR 1.2, 5.7) years. Overall, 11% required re-operation, 35% of whom had a Mitroflow and 65% were <21 years old. Time to re-operation varied among valve type (p=0.020). Crude 3-year rate was 20% in patients ≤21. Smaller valve size indexed to BSA was associated with re-operation (21.7 vs. 23.5 mm/m2). Predictors of reintervention by multivariable analysis were younger age (29% increase in hazard per 5-year decrease, p<0.001), Mitroflow (HR=4 to 8 versus other valves), and smaller valve size (20% increase in hazard per 1 mm decrease, p=0.002). The overall 1, 3 and 5-year survival rates were 94%, 90% and 85% without differences by valve (p=0.19).   Significance: This study showed younger age at surgery as a risk for reintervention which is consistent finding from previous studies. From the risk analysis, a larger valve size, an older age (>21 years old), and the valve other than Mitroflow will be recommended in young adults with congenital heart disease.   Comment: It is quite surprising that overall mortality in such a short follow-up period (2.9 years) was 16.2% and high. Of note, more than one thirds of patients died of unknown cause. Overall reintervention rate was about 10% and this is not bad as expected, considering study population was median age of 45 years old. The Sorin Mitroflow required reintervention the most, accounting 45% even with relative short period follow-up of 2.5 years. St. Jude’s valve was used for the most youngest population about 9.8 years old but resulted in no reintervention. This surprises us as this study demonstrated younger age < 21years as a risk for reintervention. One of the reasons may be small number (N=6) of patients having St. Jude’s valve and further study is necessary for a strong conclusion. This study showed a larger valve size was at low risk for reoperations. Patients with no reintervention had more aortic annulus enlargement and concomitant procedure, such as aortic root replacement. Therefore, it might be important to implant a larger size valve even it requires complex procedure as it will lower the risk of reintervention. Approximately 80% of patients had only Aspirin after surgery. This is very important for patients’ QOL, especially in young population.