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Small aortic root in childhood: surgical options
D B Ross1, G A Trusler, J G Coles
1Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Pediatric aortic valve replacement often requires annular enlargement. Anterior annular enlargement showed higher early mortality but similar long-term survival compared to posterior techniques in this study.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease
- Valvular Heart Disease
Background:
- Pediatric aortic valve replacement (AVR) is challenging due to complex left ventricular outflow tract (LVOT) obstruction.
- Annular enlargement techniques are frequently necessary for successful AVR in children.
Purpose of the Study:
- To evaluate the outcomes of two distinct annular enlargement techniques in pediatric patients undergoing AVR.
- To compare survival rates and identify factors influencing outcomes in this cohort.
Main Methods:
- Retrospective review of 32 children undergoing AVR with annular enlargement between 1977 and 1991.
- Two primary techniques: posterior patch annuloplasty (n=11) and anterior annular enlargement (aortoventriculoplasty, n=22).
- Analysis of early mortality, late mortality, and actuarial survival based on technique and age.
Main Results:
- Posterior annuloplasty had one early and one late death. Anterior annuloplasty had a 22% hospital mortality rate.
- Actuarial survival was 78% at 5 years and 65% at 10 years post-repair.
- Infants under 1 year had significantly worse 5-year survival (33%) compared to older children (88%).
Conclusions:
- Both posterior and anterior annular enlargement techniques can be employed for pediatric AVR.
- Younger children, particularly infants, face higher mortality risks.
- Survivors demonstrated good outcomes without reoperations due to somatic growth.
Abstract:
Aortic valve replacement in the pediatric population is complicated by the often complex nature of the left ventricular outflow tract obstruction. Techniques to enlarge the annulus frequently are necessary. From 1977 to 1991, 32 children underwent an annular enlargement procedure at The Hospital for Sick Children, Toronto. During this same era, 110 children underwent a total of 138 aortic valve replacements. Eleven had the annulus enlarged with a posterior patch technique and implantation of a valve (mechanical 8, porcine heterograft 2, homograft 1) ranging from 20 to 25 mm in diameter. Twenty-two children had an anterior annular enlargement (aortoventriculoplasty) and aortic valve replacement with a valve (mechanical 8, porcine 2, homograft 12) 12 to 27 mm in diameter. One child had a posterior patch enlargement performed, followed by a second operation involving anterior annular enlargement. There was one early death in the posterior annuloplasty group and one late death due to failure of a bioprosthetic valve. There were five hospital deaths in the anterior annuloplasty group (22%; 70% confidence interval [CI], 14% to 32%) and two late deaths. Actuarial survival for the 32 children was 78% (70% CI, 70% to 86%) at 5 years and 65% (70% CI, 48% to 82%) at 10 years after repair. Younger children (age less than 1 year) had a significantly worse survival at 5 years (33%; 70% CI, 14% to 52%) than older children (88%; 70% CI, 82% to 95%). The survivors are well, and no reoperations have been necessary because of the children's outgrowing their valve.