LATE RESULTS AND REINTERVENTION AFTER AORTIC VALVOTOMY FOR CRITICAL AORTIC-STENOSIS IN NEONATES AND INFANTS

Background. Many centers have adopted balloon valvuloplasty for treatm ent of infants with critical aortic stenosis because of historically p oor early results and a lack of long-term results with surgical valvot omy. We evaluated our results with open aortic valvotomy over the past decade, specifically examining factors influencing survival and reint ervention in the current era. Methods. From 1986 to 1996, 37 infants i n the first 3 months of life underwent open aortic valvotomy for criti cal aortic stenosis. All patients underwent cardiopulmonary bypass, va lvotomy, and valve debridement under direct vision with standard techn iques. Results. Early mortality was 11% (4 of 37, 70% confidence limit 7% to 20%) and all early deaths were in neonates less than 2 weeks of age. Late death occurred in 6 patients a mean of 10 +/- 12 months (ra nge, 2 to 36 months) after valvotomy. Actuarial survival, including op erative deaths was 92% +/- 6% at 1 month, 78% +/- 9% at 1 year, and 73 .4% +/- 10% at 10 years. In a multifactorial regression analysis, the best predictors of death were the presence of endocardial fibroelastos is and small body surface area and the best predictor of the need for late reintervention was preoperative aortic annular size. Thirteen pat ients required reintervention: repeat operation in 7 patients, balloon valvuloplasty in 3 patients, and both balloon valvuloplasty and reope ration in 3 patients. Actuarial freedom from reintervention postoperat ively is 97% +/- 3% at 1 month, 73% +/- 9% at 1 year, and 55% +/- 11% at 10 years. Reintervention was for recurrent left ventricular outflow obstruction in 9 patients and mixed aortic stenosis and aortic insuff iciency in 4. Echocardiography 4.3 +/- 2.5 years after aortic valvotom y in survivors who have not required reintervention (n = 20) revealed a Doppler peak instantaneous systolic gradient of 37 +/- 14 mm Hg and mild or less aortic regurgitation in 16 patients and moderate aortic r egurgitation in 4 patients. Conclusions. Current surgical results with critical aortic stenosis in the neonate and young infant are acceptab le in terms of both late survival, reintervention, and functional resu lts in the majority of patients. Newer interventions, such as balloon valvuloplasty, should be carefully evaluated for long-term results and should be compared more appropriately to current surgical results to determine the best treatment modality for the neonate and infant with critical aortic stenosis. (C) 1998 by The Society of Thoracic Surgeons .