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Ann Thorac Surg 1997;64:1223
© 1997 The Society of Thoracic Surgeons

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Correspondence

Aortic Valve Repair in Children

Department of Cardiac Surgery, Prince Sultan Cardiac Center, Armed Forces Hospital, PO Box 99911, Riyadh 11625, Saudi Arabia

To the Editor:

We read with interest the article by Tolan and associates [1] published in your journal recently. The technique employed by them at Wessex Cardiothoracic Center, Southampton, UK, seems very simple. They have managed to create a tricuspid trisinusoidal valve in children with congenital bicuspid aortic valve stenosis, using a triangular piece of bovine pericardium.

Attempts at aortic valve repair in young patients with predominantly rheumatic aortic regurgitation were made in our center at Riyadh, Saudi Arabia, in 1986 to 1987. We used a patch of bovine pericardium for cusp extension of the diseased aortic valve with good immediate and medium-term results [2]. However the long-term results in 20 patients operated on at our center were not very encouraging. Most of the patients had to have aortic valve replacement for worsening aortic regurgitation in 2 to 5 years' time. At the subsequent operation the bovine pericardium was found to be severely fibrosed. In some of the cases the bovine pericardial patch had "resorbed" to a lesser or greater extent and had been replaced by fibrosis extending into the native valve cusps. This extensive fibrous replacement made the aortic regurgitation worse with the passage of time. Although the patient characteristics and the basic pathology of the aortic valve in these two series is very different, we believe the bovine pericardial patch might behave very similarly and contribute to increasing aortic regurgitation in the long term in the 6 patients presented by Tolan and associates.

We congratulate the group at Southampton for their work. We hope to see a longer follow-up and maybe a larger number of patients with aortic valve repair for congenital bicuspid aortic stenosis in the coming years. We suggest that echocardiographic assessment of such patients should be included in the follow-up period. Repair of the aortic valve in young children, if successful in maintaining acceptable hemodynamic function of the valve for a few years, may be an achievement in its own right, as a larger prosthesis may be implanted in a growing child after a few years.

References

1. Tolan MJ, Daubeney PE, Slavik Z, Keeton BP, Salmon AP, Monro JL. Aortic valve repair of congenital stenosis with bovine pericardium. Ann Thorac Surg 1997;63:465–9.[Abstract/Free Full Text]
2. Al Fagih MR, Al Kassah SM, Ashmeg A. Aortic valve repair using bovine pericardium for cusp extension. J Thorac Cardiovasc Surg 1988;96:760–4.[Abstract]

Reply

Wessex Cardiothoracic Centre, Mailpoint 46, Southampton General Hospital, Tremona Rd, Southampton SO16 6YD, United Kingdom

To the Editor:

We thank you for the opportunity to reply to the letter from Uddin and colleagues, and share their concern regarding the long-term function of bovine pericardium for aortic valve repair. All 6 patients had echocardiography in the early postoperative stage and recently. As was shown in the table in our article, there has been some slight increase in the amount of regurgitation in patients more than 30 months postoperatively. However, neither this nor the small residual aortic valve gradients have resulted in any need for reoperation, and all the patients are well, the longest follow-up now being more than 5 years.

We have reviewed all patients undergoing aortic valvotomy in our unit in the last 2 years, and it would seem that as a large proportion have bicuspid valves, many other patients would have had valves suitable for this operation. It is particularly appropriate for bicuspid valves in which there is little or no cuspal fusion, and incising the raphe allows for a marked increase in valve orifice and the pericardial suspension prevents or minimizes regurgitation.

Obviously we are following up these patients closely and hope to find many more suitable patients. However, as Uddin and colleagues point out, even if eventually the valves become regurgitant the child will hopefully have grown enough to allow valve replacement. This technique therefore seems a good alternative to initial valve replacement, including the Ross procedure or leaving the valve with important stenosis.

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James L. Monro Michael J. Tolan Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Uddin, S. A. Articles by Salmon, A. P. Search for Related Content PubMed PubMed Citation Articles by Uddin, S. A. Articles by Salmon, A. P.