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Ross procedure or complex aortic valve repair using pericardium in children: A real dilemma
Pichoy Danial1, Asma Neily2, Margaux Pontailler2
1Pediatric Cardiac Surgery, Necker Sick Children's Hospital and Paris University, Paris, France; Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France.
Insights
Aortic valvuloplasty and the Ross procedure show similar midterm outcomes for complex pediatric aortic valve lesions. Aortic valvuloplasty may be a suitable first-line treatment, potentially allowing for a future Ross procedure.
Area of Science:
- Pediatric cardiology
- Cardiac surgery
- Aortic valve disease
Background:
- Complex aortic valve lesions in children often require surgical intervention.
- The Ross procedure and aortic valvuloplasty are established treatments, but their comparative outcomes for complex cases remain debated.
Purpose of the Study:
- To compare the midterm outcomes of the Ross procedure versus aortic valvuloplasty in pediatric patients with complex aortic valve lesions.
- To evaluate survival, reintervention rates, and infective endocarditis incidence between the two surgical approaches.
Main Methods:
- Retrospective study of 126 pediatric patients (<18 years) treated between 2006-2017 for complex aortic valve lesions requiring pericardial patch repair.
- Propensity score matching was employed to create comparable groups for the Ross procedure and aortic valvuloplasty.
Main Results:
- Propensity score matching identified 34 pairs of patients with similar characteristics.
- At 8 years, survival (94.1% vs. 91%), overall reintervention freedom (50.1% vs. 69%), and infective endocarditis freedom (100% vs. 85.9%) were similar between aortic valvuloplasty and the Ross procedure.
- However, freedom from left ventricular outflow tract reintervention was significantly lower after aortic valvuloplasty (50.1%) compared to the Ross procedure (100%).
Conclusions:
- Both aortic valvuloplasty and the Ross procedure demonstrate comparable 8-year outcomes concerning mortality, reoperation, and infective endocarditis.
- Aortic valvuloplasty, particularly using a pericardial patch, can be considered a primary treatment strategy for complex aortic valve lesions in children.
- This approach may preserve the option for a subsequent Ross procedure if needed.
Objective:
Difficult to repair aortic valve lesions, requiring the use of a valve substitute, remain controversial in the face of the Ross procedure, despite undeniable technical advances. This study was undertaken to compare midterm outcomes of children treated using the Ross procedure or aortic valvuloplasty for complex aortic valve lesions.
Methods:
Between January 2006 and December 2017, 126 patients aged younger than 18 years were treated for complex aortic stenosis and/or aortic insufficiency and were included in this retrospective study. Only aortic valve lesions requiring repair with an autologous or heterologous pericardial patch were considered complex lesions. Propensity score framework analyses were used to compare outcomes of the Ross and aortic valvuloplasty groups while controlling for confounders.
Results:
Among the 126 patients with complex aortic valve lesions, propensity score matching selected 34 unique pairs of patients with similar characteristics. Survival (aortic valvuloplasty, 94.1%; Ross, 91%; P = .89), freedom from overall reintervention (aortic valvuloplasty, 50.1%; Ross, 69%; P = .32), and freedom from infective endocarditis at 8 years (aortic valvuloplasty, 100%; Ross, 85.9%; P = .21) were similar. However, freedom from reintervention in the left ventricular outflow tract at 8 years was lower after aortic valvuloplasty than after the Ross procedure (50.1% vs 100%, respectively; P = .001).
Conclusions:
Aortic valvuloplasty and the Ross procedure yielded similar 8-year outcomes regarding death, reoperation, and infective endocarditis although aortic valvuloplasty tended to be associated with fewer cases of infective endocarditis. Aortic valvuloplasty using a pericardial patch can be chosen as a first-line strategy for treating complex aortic valve lesions and might offer the possibility of a later Ross procedure.
