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Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement
Published on: December 11, 2017
Early experience with valve-sparing aortic root replacement in children
Luca A Vricella1, Jason A Williams, William J Ravekes
1Division of Pediatric Cardiac Surgery, The Johns Hopkins University Hospital, Baltimore, Maryland, USA. lvricella@jhmi.edu
Insights
Aortic valve-sparing root replacement is a safe and effective option for children with ascending aorta aneurysms, offering durable results with minimal complications. Reimplantation techniques show superior long-term outcomes compared to remodeling.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Thoracic Surgery
Background:
- Aortic valve-sparing root replacement (AVSRR) is established in adults for ascending aorta aneurysms.
- Limited pediatric experience exists, despite AVSRR's advantages in avoiding valve prostheses in children.
Purpose of the Study:
- To evaluate the outcomes of AVSRR in pediatric patients.
- To compare different AVSRR techniques in children.
Main Methods:
- Retrospective clinical study of 19 pediatric patients undergoing AVSRR between 1997 and 2004.
- Data collected via chart review and outpatient follow-up, including echocardiography.
Main Results:
- No operative mortality; one reoperation for bleeding.
- 15.8% required late aortic valve replacement; most had no or mild insufficiency.
- Reimplantation procedures showed no reoperations or more than mild insufficiency.
Conclusions:
- AVSRR is a viable alternative to prosthetic root replacement in children.
- Reimplantation techniques offer more durable results than remodeling for pediatric aortic root enlargement.
Background:
Aortic valve-sparing root replacement has become an established treatment for adults with aneurysms of the ascending aorta, but there is limited experience in children, for whom the advantages of avoiding valve prostheses are particularly attractive.
Methods:
A retrospective clinical study was undertaken to examine results of aortic valve-sparing operations in pediatric patients at a single institution. Clinical and echocardiographic data were obtained from chart review and outpatient follow-up examination.
Results:
Between 1997 and 2004, 19 children underwent aortic valve-sparing root replacement. Mean age was 12.2 +/- 4.4 years, and mean weight was 51.5 +/- 22.9 kg. Median length of clinical follow-up was 58 months (range, 5 to 91). Fifteen of 19 patients (78.9%) had Marfan syndrome and 1 had aortic root dilation late after the arterial switch operation. Mean preoperative root diameter was 4.7 +/- 0.6 cm, with an average Z score of 7.7 +/- 1.9. Fourteen patients (73.7%) underwent root remodeling, whereas 5 (26.3%) had a reimplantation procedure. One patient required concomitant mitral valve repair. There was no operative mortality and only 1 reoperation for bleeding (5.3%). Median length of hospital stay was 5 days (range, 3 to 12). At latest follow-up, 3 of 19 patients (15.8%) have required late aortic valve replacement. Fifteen patients have no or mild aortic valve insufficiency, and 1 has moderate but stable valve regurgitation. No patient with a reimplantation procedure has had a reoperation or more than mild insufficiency, and no patient has suffered endocarditis or thromboembolism.
Conclusions:
Valve-sparing aortic root replacement is a viable alternative to root replacement with mechanical or biological prostheses in children, and can be accomplished with minimal morbidity and mortality. Reimplantation procedures appear to have more durable results than root remodeling techniques, and should be strongly considered for pediatric patients with aortic root enlargement secondary to connective tissue disorders and other forms of congenital heart disease.
