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Are Mechanical Prostheses Valid Alternatives to the Ross Procedure in Young Children Under 6 Years Old?
Bahaaldin Alsoufi1, Jessica H Knight2, James St Louis3
1Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky.
Insights
Mechanical prostheses (MP) showed similar early survival to the Ross operation in young children but diverged significantly after 17 years, with higher attrition in the MP group. Reoperation rates were also higher with MP, indicating long-term risks.
Area of Science:
- Pediatric Cardiac Surgery
- Biomaterials in Medicine
- Congenital Heart Disease Treatment
Background:
- Aortic valve replacement in young children presents surgical challenges.
- Mechanical prostheses (MP) are less commonly used than the Ross operation in this population.
Purpose of the Study:
- To compare transplant-free survival and cardiac reoperation rates between the Ross operation and mechanical prostheses (MP) in young children.
- To identify factors influencing outcomes in pediatric aortic valve replacement.
Main Methods:
- Retrospective analysis of 124 children (aged 1-6 years) from the Pediatric Cardiac Care Consortium database (1982-2003).
- Comparison of outcomes between patients who underwent the Ross operation (n=84) and MP (n=40).
- Multivariable regression analysis to explore variables affecting survival.
Main Results:
- No significant difference in hospital mortality or 15-year transplant-free survival between Ross and MP groups.
- Survival diverged significantly at 25 years, with lower survival in the MP group (68.9% vs 91.3%).
- Cumulative incidence of cardiac reoperation at 10 years was higher for MP (53.6%) compared to Ross (37.7%).
Conclusions:
- Mechanical prostheses (MP) use in young children is associated with comparable early survival to the Ross operation.
- Long-term survival is significantly worse with MP, likely due to late valve and reoperation complications.
- There was a trend towards increased Ross operation utilization over the study period.
Background:
Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used.
Methods:
We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n = 84) or MP (n = 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes.
Results:
Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P = .24) or 15-year transplant-free survival (94.1% vs 87.5%, P = .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P = .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P = .78] vs 6.0 [95% confidence interval, 0.6-63.1; P = .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P = .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement.
Conclusions:
Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve- and reoperation-related complications.
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