Open commissurotomy for critical isolated aortic stenosis in neonates

Background. The optimal management of critical aortic stenosis in early inf ancy remains controversial. The aim of this study was to assess the early a nd late outcomes following open surgical valvotomy for critical aortic sten osis in neonates and to provide a framework of data against which current r esults of other treatment approaches can be evaluated. Methods. Eighteen consecutive neonates (mean age 9.2 days, range 1 to 26 da ys) undergoing an open valvotomy for critical isolated aortic stenosis (the standard treatment for this condition in our unit) between 1984 and 2000 w ere studied. The mean aortic valve gradient was 79.4 mm Hg. Twelve neonates received prostaglandins and 10 received inotropic agents preoperatively. F ollow-up was complete (mean 8.1 years, range 1 month to 15 years). Results. There was no operative mortality. At discharge, the mean aortic va lve gradient was 37.2 mm Hg, with 6 patients having mild and 2 having moder ate aortic regurgitation. Six patients required a reoperation; 3 of these h ad an aortic valve replacement at 9 to 11 years of age. Kaplan-Meier 5- and 10-year freedoms from any aortic reoperation or reintervention were 85 and 55%, respectively; 5- and 10-year freedoms from aortic valve replacement w ere 100 and 79%, respectively. A 14-year-old boy died from endocarditis 4 y ears following an aortic valve replacement in another unit. Kaplan-Meier 10 -year survival was 100%. All survivors are in New York Heart Association I class and are leading normal lives. Their mean aortic valve gradient is 34. 5 mm Hg, and none has significant aortic regurgitation. Conclusions. Open valvotomy for critical aortic stenosis in neonates carrie s a low operative risk and provides lengthy freedom from recurrent stenosis or regurgitation. Reoperations are inevitable, but aortic valve replacemen t can be delayed until the implantation of an adult-sized prosthesis is pos sible. Late survival is excellent. We consider open surgical valvotomy to b e the treatment of choice for critical neonatal aortic stenosis. (C) 2001 b y The Society of Thoracic Surgeons.