MORPHOLOGIC DETERMINANTS FAVORING SURGICAL AORTIC VALVULOPLASTY VERSUS PULMONARY AUTOGRAFT AORTIC-VALVE REPLACEMENT IN CHILDREN

The pulmonary autograft is being used with increasing frequency to rep lace the diseased aortic valve in the pediatric population, Attempted surgical aortic valvuloplasty with an unacceptable result and return t o cardiopulmonary bypass for aortic valve replacement with a pulmonary autograft results in prolonged bypass time and increased potential fo r morbidity. Therefore, the ability to predict an unsuccessful outcome for valvuloplasty would be of significant clinical benefit. This issu e is addressed in the present study. Methods: Twenty-two patients (med ian age 5.7 years, range 3 weeks to 14 years) with bicuspid (n = 11), tricuspid (n = 9), or quadricuspid (n = 2) aortic valves underwent val vuloplasty for aortic stenosis (n = 9), aortic regurgitation (n = 7), or a combination (n = 6). Previous related procedures included balloon aortic valvuloplasty (n = 3) and open surgical valvotomy (n = 1). Med ian pressure gradient across the aortic valve was 80 mm Hg. Surgical v alvuloplasty techniques included thinning of leaflets (n = 18), commis surotomy (n = 15), suspension of reconstructed leaflet to the aortic w all (n = 10), closure of leaflet fenestration (n = 5), shortening of f ree edge of prolapsed cusp (n = 4), repair of torn leaflets (n = 3), a nd augmentation of scarred leaflets with autologous pericardium (n = 3 ). Concomitant subvalvular and supravalvular stenosis were repaired in nine and four patients, respectively. In five patients, during the sa me hospital stay, a failed valvuloplasty was converted into a valve re placement with a pulmonary autograft because of residual or resultant stenosis (n = 3) or regurgitation (n = 2). Results: No early or late d eaths occurred. At a median follow-up of 16.3 months the median pressu re gradient across the aortic valve in the 15 patients with preoperati ve stenosis or combined stenosis and regurgitation was 16 mm Hg (p < 0 .01 versus preoperative gradient). Of the 22 patients, the aortic valv e functioned normally (defined as less than or equal to mild stenosis or regurgitation, or both) in 14 patients (including five patients wit h valve replacement); four patients had stenosis (gradients 40, 45, 60 , and 60 mm Hg), two patients had regurgitation, and two patients had combined stenosis (gradients 40 and 50 mm Hg) and regurgitation. Three of the patients with recurrent stenosis underwent secondary surgical valvuloplasty without improvement. Outcome after valvuloplasty was exa mined according to valve structure: six of nine tricuspid valves funct ioned normally, whereas only three of 13 nontricuspid valves functione d normally (p = 0.07). Patients with a nontricuspid aortic valve and r egurgitation had a high probability of requiring immediate valve repla cement (p = 0.009). The actuarial freedom from significant native valv e stenosis or regurgitation at 24 months was 82% for tricuspid valves and 36% for nontricuspid valves (p = 0.007). Conclusions: (1) Surgical aortic valvuloplasty should be the preferred approach when the aortic valve is tricuspid. (2) In contrast, aortic valve replacement with a pulmonary autograft should be the preferred strategy in the presence o f a nontricuspid aortic valve (especially when the aortic valve is reg urgitant) and after failed surgical valvuloplasty.