AORTIC-VALVE REPAIR AND REPLACEMENT AFTER BALLOON AORTIC VALVULOPLASTY IN CHILDREN

Background. Little is known about the incidence, indications, and resu lts of surgical repair or replacement of the aortic valve after balloo n aortic valvuloplasty (BAV) for congenital aortic stenosis in childre n. This study was designed to evaluate patterns of failure requiring o peration after BAV for congenital aortic stenosis and to review our ex perience with successful repair, rather than replacement, of selected aortic valves after BAV. Methods. From March 1986 to June 1995, 60 pat ients with congenital aortic stenosis aged 1 day to 27 years (mean sta ndard deviation, 7.3 +/- 6 years) underwent BAV. Twenty-three patients (38%) required operation a mean of 44 +/- 37 months (range, 1 to 110 months) after BAV, because of severe aortic insufficiency in 13 patien ts and recurrent or residual aortic stenosis in 10 patients. Severe ao rtic insufficiency was invariably due to avulsion of a cusp from the a nnulus, with resulting cusp prolapse and insufficiency. Operative inte rvention consisted of valve replacement in 14 patients and valve repai r in 9 patients. Repair techniques included reattachment of an avulsed cusp to the aortic annulus, relief of commissural fusion, and debride ment of thickened cusps. Results. Actuarial freedom from surgical inte rvention after BAV was 88% +/- 4% at 1 year, 70% +/- 6% at 5 years, an d 51% +/- 12% at 9 years. The need for aortic valve operation was unre lated to age at the time of BAV, indication for operation (aortic insu fficiency versus aortic stenosis), age at operation, or preoperative g radient. All patients survived aortic valve operation; there was one l ate death at an average follow-up of 27 +/- 20 months (range, 2 to 61 months) after aortic valve operation. Stenosis was well relieved in al l patients undergoing valve replacement. The 9 valve repair patients h ave been followed for 22 +/- 14 months (range, 1 to 47 months). Echoca rdiographic follow-up of the valve repair patients revealed a mean res idual aortic stenosis peak instantaneous gradient of 32 mm Hg and mild aortic insufficiency or less in all patients. Conclusions. Aortic val ve operation is required in 5% to 7% of patients yearly after BAV. The need for operation appears to be unrelated to age at the time of BAV; aortic insufficiency predominates over aortic stenosis as an indicati on for operative intervention. Valve repair can be applied in some pat ients after BAV with good intermediate-term results and may delay the need for aortic valve replacement.