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Ann Thorac Surg 1996;61:1297-1298
© 1996 The Society of Thoracic Surgeons
Division of Cardiac and Thoracic Surgery, Department of Surgery, Children's Hospital and Health Center of San Diego, Children's Heart Institute of San Diego, San Diego, California
In this issue of The Annals of Thoracic Surgery, Hawkins and associates [1] seek to examine the ``incidence, indications, and results of surgical repair or replacement of the aortic valve after balloon aortic valvuloplasty (BAV) for congenital aortic stenosis in children.'' In the process, Hawkins and associates present good evidence that aortic valve repair is still possible after disruption of the aortic valve by balloon dilation. Twenty-three of 60 patients undergoing BAV required operation at 44 ± 37 months after BAV. Creative techniques including leaflet repair, leaflet shaving, and commissurotomy were used to salvage nine valves. Fourteen patients underwent various types of valve replacement.
Historically, the early and late mortality and morbidity after aortic valve replacement in infants and children were substantial. In recent years, enthusiasm for the Ross procedure (pulmonary autograft) has created the conceptthat a ``curative'' operation could be performed for aortic valve disease in infants and children [2, 3]. However, not all pulmonary autograft valves are competent, and some have required re-replacement. The homograft in the pulmonary position will not grow and on some occasions may become inexplicably stenotic. It is also likely that most infants and many small children will require reoperation for replacement of the homograft in the pulmonary position. Despite these concerns, there is no question that the pulmonary autograft is an excellent choice for an infant, child, young adult, or active older person who requires aortic valve replacement.
The satisfactory early results for valve repair in 9 patients in this report suggest that modern valve repair techniques can be useful after BAV. This is good news, for successful valve repair is certainly more desirable than a small, nongrowing bioprosthetic or mechanical valve, and repair allows for the Ross procedure to be deferred until an adult-sized valve can be implanted in the pulmonary position. The follow-up is not long, and the reader must not rush to conclusions regarding valve repair. The results of Hawkins and associates' study should be compared with the report by van Son and colleagues [4] that suggests that bicuspid, insufficient aortic valves cannot be successfully repaired. In contrast, Hawkins and associates were able to repair patients with bicuspid aortic valves disrupted by balloon valvuloplasty. They used multiple stepwise logistic regression analysis to define factors associated with successful valve repair. The most important factors determined were a shorter interval between BAV and aortic valve operation and a more recent year of operation. This is not surprising because the technical aspects of valve repair have been refined at an accelerated pace in the last decade and it is possible that an ongoing process of fibrosis and scarring renders the disrupted leaflet nonreparable if the repair operation is deferred for a considerable period of time.
Hawkins and associates are cautious in their conclusions because the follow-up only averages 22 months. In the discussion, they hint at a much more important area of controversy in modern cardiovascular surgery. Balloon aortic valvuloplasty has become the procedure of choice for aortic stenosis at many centers. This decision has been based on a comparison of a number of older surgical series with recent reports describing the efficacy of BAV. Unfortunately, interventional cardiologists are comparing apples to oranges. The surgical literature abounds with reports of various techniques used in infancy such as inflow occlusion aortic valvotomy, blind dilation of the aortic valve from the left ventricular apex with or without cardiopulmonary bypass, and limited exposure of the valve on cardiopulmonary bypass. The early and late outcomes in these surgical series may have been suboptimal due to the lack of appropriate preoperative determination of the fate of the left ventricle and the presence of associated abnormalities.
Today, the aortic valve can be carefully exposed in most newborns and all older infants and children using conventional cardiopulmonary bypass techniques with low flow or circulatory arrest. Direct exposure of the aortic valve allows precise incision of the commissures, mobilization of the leaflets, and shaving of excrescences when appropriate [5, 6]. Pericardial patch augmentation of the supravalve aorta is a simple addition to this approach, if necessary. In addition, surgical valvotomy is rarely if ever associated with acute rupture of a valve leaflet or injury to the iliac or femoral arteries. It is an interesting phenomenon that some well-known centers that advocate complex and precise corrective surgical procedures on newborns prefer to have the aortic valve ``dilated'' in a blind fashion.
The study that has not been published and probably never will be published would compare apples to apples and oranges to oranges. May I suggest that a group of comparable infants determined to have a satisfactory left ventricle [7], both in terms of size and function, be randomized to creative aortic valve operation and BAV. Until we have the early and late results of such a study, we must content ourselves with conclusions drawn from heterogeneous groups of patients treated by a variety of surgical techniques or BAV. In the meantime, we should feel pleased that Hawkins and associates have joined Caspi and colleagues [8] in demonstrating that aortic valve repair is a reasonable therapy for infants and small children after failure of BAV. Because pulmonary autograft insertion is probably not a curative operation in those patients requiring implantation of a small homograft in the pulmonary position, creative surgical valve repair, not BAV, may be the optimal treatment for infants and children presenting with predominant aortic valve stenosis, even when there is a minor degree of aortic insufficiency.
Footnotes
Address reprint requests to Dr Lamberti, Division of Cardiac and Thoracic Surgery, Department of Surgery, Children's Hospital and Health Center of San Diego, Children's Heart Institute of San Diego, 3030 Children's Way, Suite 310, San Diego, CA 92123.
References
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  V. L. Vida, T. Bottio, O. Milanesi, E. Reffo, R. Biffanti, R. Bonato, and G. Stellin Critical Aortic Stenosis in Early Infancy: Surgical Treatment for Residual Lesions After Balloon Dilation Ann. Thorac. Surg., January 1, 2005; 79(1): 47 - 51. [Abstract] [Full Text] [PDF]
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