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Extended aortic root replacement with aortic allografts or pulmonary autografts in children
H K Najm1, J G Coles, M D Black
1Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children andthe University of Toronto Faculty of Medicine, Ontario, Canada.
Insights
Left ventricular outflow tract enlargement using aortic allografts or pulmonary autografts shows good early results in older children with complex obstructions. However, urgent procedures in neonates carry higher mortality risks.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease
- Aortic Valve Surgery
Background:
- Complex left ventricular outflow tract obstruction (LVOTO) in children often requires surgical intervention.
- Aortic root enlargement with allografts or autografts is a potential treatment strategy.
Purpose of the Study:
- To evaluate the early outcomes and effectiveness of left ventricular outflow tract enlargement using aortic allografts or pulmonary autografts in pediatric patients with complex LVOTO.
Main Methods:
- Retrospective review of 30 children (January 1987-June 1997) undergoing aortic root enlargement and replacement with aortic allograft (n=22) or pulmonary autograft (n=8).
- Predominant diagnosis was complex LVOTO (n=19), with 11 cases associated with aortic incompetence.
- Most patients (n=27) underwent Konno aortoventriculoplasty; concomitant procedures included valvotomy, balloon dilatation, septal myectomy, and mitral valve repair.
Main Results:
- In-hospital mortality was 17% (5/30), primarily in infants (<2 months) with acute aortic incompetence requiring urgent surgery.
- One late sudden death occurred at 3 months post-operation.
- Follow-up echocardiograms (n=23) showed a significant reduction in LVOTO gradient (65 to 11 mm Hg, P=.001) and improved Z-scores (-0.5 to 4.1, P<.001), with trivial or mild aortic incompetence in most survivors.
Conclusions:
- Urgent aortic root enlargement in neonates with decompensation is associated with increased mortality.
- Aortic allograft or pulmonary autograft implantation for root enlargement demonstrates favorable early results in older children with complex LVOTO.
Objectives:
To evaluate the early results and effectiveness of left ventricular outflow tract enlargement with aortic allograft or pulmonary autograft in children with complex left ventricular outflow tract obstruction.
Method:
The records of 30 children who underwent aortic root enlargement and replacement with either an aortic allograft (22 patients) or pulmonary autograft (8 patients) between January 1987 and June 1997 were reviewed. The predominant diagnosis was complex left ventricular outflow tract obstruction (n = 19), associated with aortic incompetence in 11 children. Before root enlargement, 27 children underwent surgical valvotomy (14 patients), balloon dilatation (10 patients), or both interventions (3 patients). Mean age at root enlargement was 5.4 +/- 3.5 years (range, 2 days-16 years). Most of the children (27 patients) underwent a Konno aortoventriculoplasty. Concomitant septal myectomy was performed in 4 children, mitral valve procedure in 5 children, and endocardial fibroelastosis resection in 1 child.
Results:
Five children (17%) died in hospital. Four of these were infants less than 2 months old. All had acute aortic incompetence as the result of recent intervention necessitating urgent operation. The fifth child, aged 10 years, died of myocardial failure 2 weeks after the operation. During the follow-up period (mean length, 4.1 +/- 2.8 years), sudden death occurred in 1 child 3 months after the operation. Follow-up echocardiograms (obtained for 23 of the surviving 24 children within 3 +/- 2.3 years) showed a left ventricular outflow tract gradient reduced from a mean of 65 to 11 mm Hg (P =.001); Z value increased from a mean of -0.5 to 4.1 (P <. 001), and aortic incompetence was trivial or mild except in 2 children.
Conclusion:
Urgent aortic root enlargement in decompensating neonates carries higher mortality rates. In older children, the early results of root enlargement and implantation of allograft or autograft are good.