Balloon Aortic Valvoplasty versus Surgical aortic Valvotomy in Children with Severe Valvular Aortic Stenosis

Abstract

Summary In 2001, in one of the very few comparative multi-centric studies existing in the field of congenital heart dis-ease, McCrindle et al. (182) compared the results of balloon valvuloplasty with surgery and found that both approaches achieved similar outcomes in terms of survival and reinter-vention.(183) Most centers are favoring only one of the two ap-proaches, following the expertise developed locally and their personal bias. The vast majority of centers (7–9) are favoring balloon valvuloplasty at this age, likely because the initial decision is in the hands of the cardiologists who are the first physicians to care for the patient and because the expertise in balloon valvuloplasty has been easier to develop than advanced surgical techniques.(183) The last 2 decades have seen an improvement of the techniques of aortic valve repair, and the expansion of their use in the adult population and it is possible that the surgi-cal procedures performed nowadays are superior than those practiced in the past (184,185). Until recently, neonatal surgery of the aortic valve was limited to blind transapical dilation of the valve or simple  90 blade commissurotomy. A third of the patients undergoing surgery in the comparative study of 2001 underwent a transapical balloon dilation, a procedure closer to balloon valvuloplasty than contemporary surgery (186). Surgeons are now realizing that in order to achieve a more durable repair it is necessary to de-bulk the leaflets from all thickening and nodular dysplasia and to resuspend with patches the incised unsupported portion of the leaf-lets.(183) Knowledge gained by a single center retrospective study will always be limited by the fact that within 1 center, 1 approach will always be favored, and expertise will main-ly be developed in that area. (183) For 14 years, both approaches were offered. Because it has been unusual to offer both approaches to patients, it was worth reviewing our experience despite the lack of randomization in order to compare their long-term out-comes especially in terms of reoperation rate and mode of failure. Survival of the entire group compares favorably to previous results with a hospital mortality of 2% and a late mortality close to 10%. As expected, the patients with the most extreme form of the disease and the patients requiring a procedure as neonates were at higher risk of mortality.(183)  91 There was a striking difference between the 2 ap-proaches in the risk of re-intervention. Clearly, patients ne-cessitating an intervention earlier in life have a higher risk of requiring re-intervention. (183) By the end of the second decade following the proce-dure, half of patients required a second procedure, but half of those remaining free of re-intervention were still show-ing significant aortic valve stenosis, and were likely to re-quire a re-intervention in the near future. (183) In this review of historical experience, patients under-going balloon valvuloplasty required re-intervention more rapidly than those undergoing surgical valvuloplasty How-ever, the 68% freedom from re-intervention at 10 years of neonates and infants undergoing surgery were still superior to the best results reported after balloon dilation of an entire pediatric population (187). In centers, where both approaches were concomitantly offered over the course of the years, and even before the present analysis was conducted, there was a gradual shift in decision-making favoring surgery over interventional cath-eterization. Believing that benefits of both approaches should not only be weighed in terms of re-intervention rates, but more importantly, in terms of the proportion of patients who may have a subsequent surgery postponed for several decades.(183)  92 At the term of follow-up close to half of the patients who underwent surgery were living with a non-stenotic, non-regurgitant native valve, a much higher proportion than if they had undergone an initial balloon valvuloplasty.(183) Hoping that a proportion of these patients may live with their native valve for more than 2 decades. Delaying by several years the re-intervention is a benefit that com-pensates for the invasiveness of surgery.(183) Majority of the patients undergoing balloon valvulo-plasty will ultimately end up with a valve replacement be-cause of the destructive nature of balloon valvuloplasty. The majority of these patients will end with a Ross proce-dure.(183) There has been evidence that up to a quarter of the pa-tients may see these autografts fail in the 2 decades follow-ing the initial Ross procedure because of the observed dila-tion of the transplanted autograft roots (188). It is believed that root dilation may be prevented by favoring the inclusion technique over the root replacement or by including the autograft in a prosthetic graft (189). Inclusion technique can only be performed in larger roots and can only rarely be performed in the pediatric age. hoping that postponing the Ross procedure to the adult age  93 will allow the use of techniques allowing better outcomes after the Ross procedure. After aortic valve repair, long-standing growth of the aortic root will be observed The growth will enable the surgeon to perform a higher propor-tion of inclusion technique at a later age.(