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Ann Thorac Surg 2006;82:1594-1597
© 2006 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Redo Aortic Valve Replacement in Children

Kirk R. Kanter, MD*, Paul M. Kirshbom, MD, Brian E. Kogon, MD

Division of Cardio-Thoracic Surgery, Department of Surgery, Emory University School of Medicine, and Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia

Accepted for publication May 31, 2006.

* Address correspondence to Dr Kanter, Division of Cardio-Thoracic Surgery, Emory University School of Medicine, 1365 Clifton Road, Atlanta, GA 30322 (Email: kkanter{at}emory.edu).

Presented at the Poster Session of the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Some children who have had an aortic valve replacement (AVR) will need valve re-replacement (redo-AVR). We analyzed our results with 38 redo-AVRs in 30 children.

METHODS: Thirty children, aged 2 months to 20 years (mean, 11.5 ± 5.4 years), underwent 38 redo-AVRs 1 month to 14 years (mean, 4.6 ± 4.5 years) after previous AVR. Seven children had a second redo-AVR and one had a third redo-AVR (his fourth AVR). Reoperation indication was primarily stenosis in 19, regurgitation in 12, endocarditis in 3, valve thrombosis-emboli in 3, and ruptured aortic aneurysm in 1. The initial valve was mechanical in 26, homograft in 7, xenograft in 4, or a Ross procedure in 1. Sixteen patients (42%) had a previous Konno procedure.

RESULTS: The new valve was mechanical (28), homograft (5), xenograft (4), or a Ross procedure (1). Twenty-five valves were upsized on re-replacement. The median valve size was 23 mm (median size increase 4 mm). Twenty-seven operations (71%) included annulus enlargement (16 redo-Konno, 8 new Konno, and 3 Manougian). Twelve children (32%) had concomitant operations including mitral valve repair-replacement (4) and right ventricular outflow tract procedure (5). Three of the 4 hospital deaths were with second or third time redo-AVR. The only death in patients with first time redo-AVR was a patient in cardiogenic shock at the time of operation.

CONCLUSIONS: Redo-AVR in children can be performed with reasonable morbidity and mortality. A larger prosthesis can often be placed in these children. Second or third time redo-AVR appears to be riskier. Earlier referral before onset of ventricular dysfunction is warranted.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Although surgical and catheter-based techniques for preserving the aortic valve in children with aortic valve disease have improved, there are a certain number of children in whom successful aortic valve salvage cannot be accomplished and therefore will need aortic valve replacement (AVR). As times goes on, some of these children will require repeat AVR (redo-AVR) due to a variety of reasons such as outgrowth of the valve, deterioration of a bioprosthetic or homograft valve, endocarditis, or pannus formation. As this population of children undergoing redo-AVR grows, we felt that it would be useful to review our experience with redo-AVR in children to determine its safety and efficacy. This is the basis of the current report.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patient Population
Since 1981 we have performed 38 redo-AVR in 30 children. Children undergoing repeat combined aortic and mitral valve replacements were excluded from this report. The clinical characteristics of the patients are shown in Table 1. The average age at the time of first AVR was 5.4 ± 4.9 years (range, 5 days to 20 years). The age at redo-AVR was 11.5 ± 5.4 years (range, 2 months to 20 years). The interval from initial AVR to redo-AVR ranged from one month to 14 years (mean 4.6 ± 4.5 years). Seven children had a second redo-AVR and one had a third redo-AVR (his fourth AVR). The indication for reoperation was primarily aortic stenosis in 19 (either outgrowth of the valve or pannus formation), predominately aortic regurgitation in 12, valve thrombosis or embolism in three, endocarditis in three, and ruptured aortic aneurysm in one. For the patients with predominantly prosthetic valve stenosis, indications for operation in asymptomatic children were a left ventricular outflow tract gradient of greater than 40 mm Hg in the face of increasing left ventricular hypertrophy by echocardiography. For asymptomatic patients whose primary indication for reoperation was prosthetic valve insufficiency, indication for reoperation was evidence of increasing left ventricular dimensions on serial echocardiographic measurements. In both the stenosis and insufficiency groups, the presence of symptoms warranted earlier operation if there was demonstrable prosthetic valve dysfunction on evaluation.


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  		Table 1. Patient Characteristics
 
The initial AVR was mechanical in 26, homograft in seven, xenograft in four, and a pulmonary autograft (Ross procedure) in one. Because our preference for mechanical valve choice changed over time, a variety of mechanical valves were utilized including Bjork-Shiley (Shiley Inc., Irvine, CA), St. Jude (St. Jude Medical, Inc, St. Paul, MN), and Carbomedics (Sulzer Carbomedics, Austin, TX) mechanical valves. Sixteen patients (42%) had a previous Konno aortoventriculoplasty, some of whom have been described previously [1, 2].

Patient follow-up was determined by periodic cardiology visits, by review of hospital and clinic records, as well as our cardiac surgery database. This retrospective study was approved by the Emory University School of Medicine Institutional Review Board.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
At the time of redo-AVR, 12 of the 38 operations (32%) had additional procedures as shown in Table 2. These procedures included mitral valve repair or replacement in four patients and right ventricular to pulmonary artery conduit or pulmonary valve replacement in four patients. Twenty-seven of the 38 reoperations (71%) involved enlargement of the aortic annulus (Table 2). Sixteen patients had a repeat Konno aortoventriculoplasty, eight had a new Konno procedure, and three had a Manougian annulus enlarging procedure.


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  		Table 2. Operative Details
 
The valve used at time of redo-AVR was mechanical in 28, homograft in 5, xenograft in 4, and a pulmonary autograft (Ross procedure) in one. Of the 26 children with a previous mechanical valve, at redo-AVR 19 received another mechanical valve, 4 received a homograft, 2 received a xenograft, and one had a Ross procedure. Of the 7 children who initially had a homograft AVR, at redo-AVR 6 received a mechanical valve and one received another homograft. Of the 4 children who initially had a xenograft AVR, one received another xenograft and the other 3 had a mechanical valve at the time of redo-AVR. Finally, the one patient with a Ross procedure received a xenograft valve at redo-AVR. Twenty-five valves were upsized at reoperation with the mean valve size increasing from 20.2 ± 4.2 mm to 23.2 ± 3.3 mm (Fig 1). The median valve size increase was 4 mm.


Figure 1
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  		Fig 1. Valve size in mm plotted against age in years at each valve replacement. Each line represents a single patient with the left side of the line representing the age and prosthetic valve size at the time of initial aortic valve replacement (AVR) and the right side of each individual line representing the age and prosthetic valve size at the time of the redo-AVR. The mean valve size increased from 20.2 ± 4.2 mm to 23.2 ± 3.3 mm (median valve size increase of 4 mm).

 
For the majority of patients in this series who received a mechanical redo-AVR, we used a standardized anticoagulation regimen based on recommendations from the American College of Cardiology and American Heart Association Task Force on Practice Guidelines [3]. This consisted of daily oral warfarin, adjusted to an international normalized ratio (INR) of 2.5 to 3.0, as well as aspirin 81 mg/day orally. Despite the young age of these patients, we have not recognized an inordinate complication rate of bleeding or thromboembolic events. There may be an under-reporting of these complications because, in general, these children were followed locally by their referring cardiologist rather than in a centralized clinic.

Of the 30 children undergoing first time redo-AVR, there was only one hospital death (mortality 3.3%) in an 18 month old child with Williams' syndrome who had previously undergone aortic root replacement with an aortic homograft. The child developed severe homograft aortic insufficiency with cardiogenic shock. Despite cardiac arrest with skin incision, a new mechanical aortic valve was placed using a Konno annulus enlargement technique. The child could not be separated from cardiopulmonary bypass and died in the operating room.

The other three deaths in this series were all in patients who were undergoing second or third time redo-AVR. All three exhibited irreversible left ventricular dysfunction during surgery and died shortly after second time (two patients) or third time (one patient) redo-AVR. Two of these patients had left ventricular dysfunction preoperatively and underwent urgent redo-AVR. The third child had an elective redo-AVR for prosthetic valve aortic stenosis. Another child developed refractory heart failure after hospital discharge and underwent successful cardiac transplantation 4 months after redo-AVR.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Although it is axiomatic that preservation of the aortic valve in a child is superior to valve replacement, a certain percentage of these children will eventually require AVR. An analysis of redo-AVRs, mostly in adults who initially received a xenograft or a homograft valve, concluded that the need for redo-AVR before patient death was higher in younger patients [4]. Allwork and colleagues [5] from London reported on 31 redo-AVRs in adults after initial homograft AVR with a mortality of 19%. The Oklahoma group identified 34 patients (mean age of 31 years) undergoing pulmonary autograft replacement of the aortic valve (a Ross procedure) who had a prior AVR with only two deaths in the redo AVR group [6].

There are many series of AVR in children and young adults which typically refer to a handful (10 or fewer) of patients who require redo-AVR [7–21]. There have been a few groups describing larger numbers of children who have undergone redo-AVR. The report by Turrentine and colleagues [22] from Indiana University identified 18 reoperations in 99 children who underwent AVR, 12 of whom had a redo-AVR with excellent results. Freedom from reoperation after initial AVR in their series was less than 50% at 10 years for the children who initially received xenografts or homografts. Even the children who initially had an AVR with a mechanical valve or a Ross procedure had an incidence of redo-AVR. Mitchell and colleagues [23] looked at 25 redo-AVRs in 23 children after initial AVR with a homograft. Their operative mortality was 8%.

In view of the apparent inevitability that increasing numbers of children who have had previous AVRs will come to reoperation, we examined our own results in this report. Our series represented a heterogeneous group of patients with a variety of initial valve substitutes (Table 1). The majority of our patients had a previous mechanical valve implanted. Although it is well known that children with xenografts and homografts will likely come to reoperation [22, 23], it was surprising that so many of our patients initially had a mechanical valve. Others have reported [16] a freedom from reoperation at fourteen years of only 54% in children who had a mechanical valve placed at their initial AVR. Our own previously reported series [2] of children undergoing a Konno aortoventriculoplasty (which allowed placement of at least a small adult-sized valve) demonstrated a freedom from reoperation of only 52% at fifteen years in the children who had a mechanical valve. The indication for reoperation in the majority of patients in this series with a previous Konno procedure with a mechanical valve was not outgrowth of the valve, but more often pannus formation as has been described previously [1, 24].

Despite the high number of patients in this series who had a prior Konno procedure (42%), we were able to increase the aortic valve size in 25 operations with a median valve increase of 4 mm. To accomplish this, the aortic annulus was enlarged in 27 (71%) operations to accommodate the larger valve (Table 2).

We did not introduce the Ross procedure to our institution until December 1994. Because it is currently our valve replacement of choice in younger children with over 50 Ross procedures with a less than 2% mortality, it is remarkable that only one patient in this series of redo-AVRs had an initial Ross procedure (the initial indication for AVR in this patient was rheumatic valve disease). Medium term results with the Ross procedure in children indicate that the need for redo-AVR is low [2, 17, 21], although others have introduced a word of caution in subsets of these patients [19].

Currently, our valve of choice in redo-AVR is a mechanical valve. We reserve xenograft valves for girls who are approaching childbearing age. We have had experience using the Ross procedure for redo-AVR in only one patient in this series in a teenager who developed recurrent noninfectious prosthetic aortic regurgitation with two previous mechanical aortic valves. He has now been followed 6.5 years after his Ross procedure with good autograft valve function but with depressed left ventricular function. We have not routinely chosen the pulmonary autograft for redo-AVR in these children even though others have demonstrated its safety in this clinical situation [6]. Our institutional bias toward mechanical valves for redo-AVR is supported by our low complication rate with anticoagulation in these growing children. Now that we have a larger experience with the Ross procedure, we would consider it in a patient undergoing redo-AVR who wishes to avoid anticoagulation for reasons of unrestricted activity or desire for childbearing. Unfortunately, in the large number of patients in this series who originally required a Konno aortic root enlargement with their original AVR (42% of this series), we have found that the previous aortoventriculoplasty can distort the right ventricular outflow or pulmonary valve, thus making the use of a pulmonary autograft unwise. Furthermore, five of the 38 redo-AVR operations involved right ventricular outflow tract reconstruction or pulmonary valve replacement which would, in itself, preclude a Ross procedure.

The operative mortality in this series was acceptably low with only one early death in the children undergoing first time redo-AVR (mortality 3.3%) in a child in cardiogenic shock who was operated on in desperation. The remaining three deaths were in children with second or third time redo-AVRs, two of whom were operated on early in this experience. This low operative mortality is comparable with other reports [22, 23].

In summary, we have shown that redo-AVR can be performed successfully in children with low mortality. Even though a large number of our patients had a previous Konno procedure, we were able to increase the valve size in the majority of operations, often using some form of annulus enlarging technique. Because of the demonstrated safety of this operation, we recommend earlier referral of these children for redo-AVR before the onset of hemodynamic instability or left ventricular dysfunction.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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