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Reinterventions in patients with congenital aortic stenosis and a commissurotomy
Mostafa Mahmoud1, Bengt Johansson2, Daniel Rinnstrom3
1Public Health and Clinical Medicine, Umeå Universitet, Umea, Sweden.
Insights
Most patients undergoing surgical commissurotomy for congenital aortic stenosis (CAS) require reintervention within 30 years. Close follow-up is crucial, as those not needing reintervention showed higher mortality.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Cardiac Surgery
Background:
- Congenital aortic stenosis (CAS) often necessitates interventions, with commissurotomy as an option for patients unsuitable for valve prostheses.
- The long-term outcomes and reintervention rates following surgical commissurotomy for CAS are not well-established.
- This study investigates the need for reinterventions after initial surgical commissurotomy using national registry data.
Purpose of the Study:
- To determine the cumulative incidence and timing of reinterventions after surgical commissurotomy in patients with CAS.
- To identify factors associated with reintervention and mortality in this patient cohort.
- To provide evidence-based recommendations for long-term follow-up strategies.
Main Methods:
- A national registry of congenital heart diseases (CHDs) was queried for patients diagnosed with CAS and undergoing an index commissurotomy.
- Follow-up data were analyzed to track reinterventions, mortality, and clinical characteristics such as left ventricular hypertrophy (LVH).
- Statistical analysis was performed to compare outcomes between patients with and without reinterventions.
Main Results:
- Out of 300 patients with CAS and index commissurotomy, 54.7% required reintervention, with a median time of 14.2 years post-operation.
- Cumulative reintervention rates reached approximately 25% at 10 years and 60% at 30 years.
- Left ventricular hypertrophy (LVH) was more prevalent in patients needing reintervention (41.3% vs. 26.8%), and mortality was higher in those without reintervention (7% cumulative incidence at 30 years).
Conclusions:
- The majority of patients with CAS undergoing commissurotomy will require subsequent reinterventions, often within 30 years.
- Higher prevalence of LVH in the reintervention group warrants close monitoring during follow-up.
- Unexpectedly higher mortality in patients without reintervention underscores the need for continued, vigilant outpatient follow-up after surgical commissurotomy.
Background:
In congenital aortic stenosis (CAS), commissurotomy is an option in patients not suitable to receive a valve prosthesis. However, there is often a need for future additional interventions on the aortic valve. The fate of the aortic valve is, however, essentially unknown. This study reports the need for reinterventions after surgical commissurotomy, based on a national register.
Materials And Methods:
The national register on congenital heart diseases (CHDs) was searched for patients with CAS, simple or associated with other CHD and an index commissurotomy with later data from follow-up.
Results:
300 patients with CAS and an index commissurotomy (mean age at the operation 7.4±7.8 years, 72.4% males) were identified. After an observation time of 27.4±10.0 years, 54.7% of the patients had a reintervention that occurred 14.2±10.1 years after the index operation. The cumulative incidence of reintervention was approximately 25% 10 years after and 60% 30 years after the index intervention. The prevalence of left ventricular hypertrophy (LVH) was higher among those that needed reintervention (41.3 vs 26.8%, p=0.023). Furthermore, eight patients died with a cumulative incidence of 7% 30 years after the index intervention, where most were (7/8) without reintervention (p=0.025). There were no additional important differences between patients with and without reintervention. The prevalence of left ventricular dysfunction and New York Heart Association class >1 was low.
Conclusion:
Most (54.7%) patients with a commissurotomy, more than half of them within 30 years and eventually all will need a reintervention. This is important information to patients, especially for women in childbearing age. The higher prevalence of LVH in the group with reintervention needs attention during follow-up. Furthermore, those without reintervention, for unknown reasons, had a higher mortality. Our data strengthen the arguments for close outpatient follow-up among patients with a previous commissurotomy.
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