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Ann Thorac Surg 2006;82:1592-1593
© 2006 The Society of Thoracic Surgeons
Department of Cardiac Surgery, Southampton General Hospital, Tremona Rd, Mailpoint 46, Southampton SO16 6YD United Kingdom
(Email: monro1711{at}aol.com).
It is refreshing to see a report from a unit [1] in which surgical valvotomy rather balloon dilation is considered the optimal treatment for neonates with critical aortic stenosis. Clearly the careful division of commissures under direct vision and the ability to shave off excrescences on the under surface of the valve cusps will produce a better valve than can be achieved with balloon dilation. However, because the cardiologists see the patients first, it is usual in most units for such patients to undergo balloon dilation, and to be fair the results are mostly good. However the occasional production of catastrophic aortic regurgitation may need the surgeons to perform an emergency Ross procedure. In this report of 36 neonates having surgical valvotomy in a 15-year period, those patients with good left ventricular function did well, but those with poor left ventricular function, as evidenced by low fractional shortening and small aortic gradient by and large did poorly. However this is not always the case and also endocardial fibroelastosis was present in 33% of survivors and 66% of those that died early. This only goes to show how difficult it is to predict the outcome in those neonates with poor left ventricular function. During the same 15-year period, 16 patients underwent balloon dilation, but many had mitral stenosis and small aortic annuli and most had poor ventricles. As the authors point out, this cannot be considered a "control" group and the results were very poor. There was a relatively high incidence of aortic regurgitation after surgical valvotomy. This could relate to the high number of monocuspid valves (although the authors discount this) or perhaps to rather over-enthusiastic incisions in the valve. Even a 2-mm incision in a fused commissure will produce a very adequate increase in the cross-sectional area. Most survivors have done well, but 6 required a Ross procedure of whom only 2 did well. The surgeon did not consider further repair at reoperation, preferring the Ross procedure. This is a pity as very often repair can produce a well-functioning valve that may allow for growth and delay valve replacement for many years. This is an admirable series from one surgeon, but we are left with the conclusion that the result you get depends more on what you start with than the method of valvotomy.
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  A. Kadner, O. Raisky, A. Degandt, D. Tamisier, D. Bonnet, D. Sidi, and P. R. Vouhe The Ross Procedure in Infants and Young Children Ann. Thorac. Surg., March 1, 2008; 85(3): 803 - 808. [Abstract] [Full Text] [PDF]
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