Wallace F, Buratto E, Schulz A, d’Udekem Y, Weintraub RG, Brizard CP, Konstantinov IE. J Thorac Cardiovasc Surg. 2022 Nov;164(5):1263-1274.e1. doi: 10.1016/j.jtcvs.2021.11.097. Epub 2022 Mar 16. PMID: 35430079
Take Home Points:
- Aortic valve repair for isolated aortic stenosis results in excellent outcomes, including half of patients need reoperation and two-thirds of patients avoid a valve replacement after 10 years.
- Tricuspid valve is technically more difficult to repair compared to a bicuspid valve, resulting in a suboptimal outcome.
Commentary from Dr. Yasuhiro Kotani (Okayama, Japan), chief section editor of Congenital Heart Surgery Journal Watch
Single center retrospective study included 111 patients with isolated aortic stenosis undergoing primary aortic valve repair between 1980 and 2016. They defined a residual left ventricular outflow tract obstruction <35mmHg and trivial or less aortic insufficiency as an optimal operative outcome.
Median age at surgery was 0.4 years (IQR: 1 month – 7.9 years) and median weight at surgery was 7.0kg (IQR: 3.7 – 25kg). 52 out 111 (47%) patients underwent aortic valve repair with the use of glutaraldehyde-treated pericardial patches for cusp extension or commissural suspension to ensure adequate coaptation of the valve cusps after relief of stenosis. Other 59 (53%) patients had a non-patch valve repair, consisted of 1 or more of the following: commissurotomy, resection of nodular dysplasia, thinning of valve leaflets, or leaflet mobilization. Early and late mortality were 0.9% and 0.9%, respectively. Freedom from aortic valve reoperation was 52.1% (95% CI, 38.7-63.8) at 10 years. Freedom from aortic valve replacement was 67.9% (95% CI, 55.4-77.5) at 10 years. An optimal outcome was achieved in 48 patients (43.2%; 48/111). Tricuspid aortic valve was associated with a suboptimal outcome (P=0.01).
This retrospective study was done at Royal Children’s Hospital, Melbourne, a world-renown institute. Outcomes were excellent, including two-thirds of patients remain free from aortic valve replacement 10 years after initial aortic valve repair. It is interesting that tricuspid valve carries a high risk for suboptimal result. The authors explained that this is a reflection of the greater technical complexity of repairing a stenotic tricuspid aortic valve.
There are several options for aortic valve repair in neonates and small infants, including catheter valvotomy, surgical repair, and Ross procedure. A catheter treatment is less invasive and may be beneficial in the neonates, but it poses a risk for the development of aortic insufficiency. Surgical repair needs the use of cardiopulmonary bypass, but it provides a precise relief of stenosis by commissurotomy and leaflet mobilization which can avoid a new-onset aortic insufficiency. The authors think it is important to delay valve replacement with the Ross procedure into school age and adolescent as we know the outcomes after Ross operation beyond infantile period is excellent in the recent era. Even though a catheter treatment is currently dominant in the management of this population, this report may give us an opportunity to reconsider the strategy for patients’ lifetime intervention.