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Outcome after aortic valve replacement in children: A systematic review and meta-analysis
Jonathan R G Etnel1, Lisa C Elmont1, Ebru Ertekin1
1Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
Insights
Pediatric aortic valve replacement outcomes vary by procedure. The Ross procedure shows lower mortality than mechanical or homograft options, though reoperation rates need further study for all types.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Medical Outcomes Research
Background:
- Pediatric aortic valve replacement (AVR) is sometimes necessary despite interest in repair.
- Evidence on outcomes after pediatric AVR is limited, often from small case series.
Purpose of the Study:
- To systematically review and meta-analyze reported outcomes of pediatric patients following aortic valve replacement.
Main Methods:
- Systematic literature search (1990-2015) for English publications on pediatric AVR.
- Inclusion of studies with more than 30 patients.
- Analysis of data from 34 publications (42 cohorts) on Ross procedure, mechanical prosthesis AVR, and homograft AVR.
Main Results:
- The Ross procedure demonstrated lower early and late mortality compared to mechanical prosthesis and homograft AVR.
- Aortic valve reoperation rates were similar for Ross and mechanical prosthesis AVR, but higher for homografts.
- No studies on bioprostheses met inclusion criteria.
Conclusions:
- Current aortic valve substitutes in children yield suboptimal results.
- There is an urgent need for improved pediatric aortic valve repair techniques and innovative replacement solutions.
Objective:
Despite an increasing interest in pediatric aortic valve repair, aortic valve replacement in children may be unavoidable. The evidence on outcome after pediatric aortic valve replacement is limited and usually reported in small case series. This systematic review and meta-analysis aims to provide an overview of reported outcome of pediatric patients after aortic valve replacement.
Methods:
A systematic literature search for publications reporting outcome after pediatric aortic valve replacement published between January 1990 and May 2015 was conducted. Studies written in English with a study size of more than 30 patients were included.
Results:
Thirty-four publications reporting on 42 cohorts were included in this review: 26 concerning the Ross procedure (n = 2409), 13 concerning mechanical prosthesis aortic valve replacement (n = 696), and 3 concerning homograft aortic valve replacement (n = 224). There were no studies on bioprostheses that met our inclusion criteria. The pooled mean patient age was 9.4 years, 12.8 years, and 8.9 years for Ross, mechanical prosthesis, and homograft recipients, respectively. Pooled mean follow-up was 6.6 years. The Ross procedure was associated with lower early (4.20%; 95% confidence interval [CI], 3.37-5.22 vs 7.34%; 95% CI, 5.21-10.34 vs 12.82%; 95% CI, 8.91-18.46) and late mortality (0.64%/y; 95% CI, 0.49-0.84 vs 1.23%/y; 95% CI, 0.85-1.79 vs 1.59%/y; 95% CI, 1.03-2.46) compared with mechanical prosthesis aortic valve replacement and homograft aortic valve replacement, respectively. No significantly different aortic valve reoperation rates were observed between the Ross procedure and mechanical prosthesis aortic valve replacement (1.60%/y; 95% CI, 1.27-2.02 vs 1.07%/y; 95% CI, 0.68-1.68, respectively), whereas homograft aortic valve replacement was associated with significantly higher aortic valve reoperation rates (5.44%/y; 95% CI, 4.24-6.98). The Ross procedure-associated right ventricular outflow tract reoperation rate was 1.91% per year (95% CI, 1.50-2.44).
Conclusions:
This systematic review illustrates that all currently available aortic valve substitutes are associated with suboptimal results in children, reflecting the urgent need for reliable and durable repair techniques and innovative replacement solutions for this challenging group of patients.
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