Aortic valve repair versus the Ross procedure in children.

BACKGROUND: Aortic valve repair and the Ross procedure are widely used in children; however, it is unclear which provides the best outcomes. METHODS: Patients who underwent primary aortic valve surgery from 1980 to 2018 were included. Propensity score matching was performed to adjust for baseline differences. RESULTS: Of 415 children, 82.7% (343/415) underwent repair and 17.3% (72/415) underwent the Ross procedure. At 15 years, survival was higher for aortic valve repair (93.9% ± 1.8% vs 80.9% ± 6.4%, P = .04); freedom from reoperation (45.7% ± 4.9% vs 48.5% ± 9.0%, P = .29) did not differ, and freedom from aortic valve reoperation was higher in the Ross procedure group (45.7% ± 4.9% vs 70.7% ± 8.0%, P < .001). When analyzed by quality of repair, acceptable repair provided the highest survival (P = .01). Acceptable repair and the Ross procedure had similar freedom from reoperation at 15 years, whereas suboptimal repair performed worse (acceptable: 54.9% ± 6.7%; Ross procedure: 48.5% ± 9.0%; suboptimal: 27.0% ± 7.7%, P < .001). Acceptable repair and the Ross procedure had similar freedom from aortic valve reoperation at 15 years, whereas suboptimal repair showed worse results (acceptable: 54.9 ± 6.7; Ross procedure: 70.7% ± 8.0%; suboptimal: 27.0% ± 7.7%, P < .001). Propensity score matching paired 66 patients who underwent the Ross procedure with 198 patients who underwent repair. At 15 years, repair was associated with better survival (98.0% ± 1.2% vs 78.5% ± 7.2%, P = .03), whereas freedom from reoperation was similar (42.6% ± 7.6% vs 50.7% ± 9.8%, P = .50). However, the Ross procedure was associated with higher freedom from aortic valve reoperation (42.6% ± 7.6% vs 72.3% ± 8.5%, P = .002). CONCLUSIONS: Primary aortic valve repair was associated with better survival than the Ross procedure, whereas overall freedom from reoperation was similar. When an acceptable intraoperative result was achieved, outcomes of repair were favorable. However, when the intraoperative result of repair was suboptimal, the Ross procedure showed better results.

Outcomes of aortic valve repair in children resulting in bicuspid anatomy: Is there a need for tricuspidization?

OBJECTIVE: We aimed to assess outcomes after aortic valve repair leading to bicuspid valve anatomy in children. METHODS: This is a retrospective study of patients who underwent aortic valve repair with creation/preservation of bicuspid aortic valve anatomy or tricuspidization of bicuspid valves between 1980 and 2016. RESULTS: Overall, 127 patients underwent bicuspid repair. Median age was 0.73 years (interquartile range, 0.1-8.9), and median weight was 8.15 kg (interquartile range, 3.9-31.7). The cohort included 22.8% neonates (n = 29), 28.3% infants (n = 36), and 48.8% children (n = 62). Repair was performed without a patch in 54.3% (n = 69). Survival at 10 years was 94.8% (95% confidence interval, 87.5-97.85). Freedom from aortic valve reoperation at 5 and 10 years was 79.9% (95% confidence interval, 71.2-86.2) and 65.6% (95% confidence interval, 53.4-75.3), respectively. Re-repair was undertaken in 53.7% (22/41). Freedom from aortic valve replacement at 5 and 10 years was 90.3% (95% confidence interval, 83.1-94.5) and 75.8% (95% confidence interval, 63-84.7), respectively. Risk factors for reoperation were age less than 1 year, unicuspid valve, and the presence of Shone complex and concomitant aortic arch repair. There were 107 patients (107/127, 84.25%) with preoperative bicuspid aortic valve morphology that was preserved. They were compared with a separate cohort of 44 patients who underwent tricuspidization of bicuspid aortic valve during the same period. There was no difference in survival or freedom from aortic valve reoperation. However, freedom from aortic valve replacement was lower after tricuspidization with 49.7% (95% confidence interval, 26.3-69.3) versus 75.8% (95% confidence interval, 62.1-85.1) after 10 years (P = .0118). CONCLUSIONS: Aortic valve repair leading to bicuspid valve anatomy in children has satisfactory long-term results. Reoperation remains common, but the need for early valve replacement can be effectively delayed.

Comparison of homografts and bovine jugular vein conduits in the pulmonary position in patients <20 years of age.

OBJECTIVE: To compare the performance of homografts and bovine jugular vein (BJV) conduits in the pulmonary position. METHODS: All patients with congenital heart disease up to age 20 years who underwent pulmonary valve replacement with homografts or BJV at 3 centers in Australia were evaluated. There were 674 conduits, with 305 (45%) pulmonary homografts (PHs), 303 (45%) BJV conduits, and 66 (10%) aortic homografts (AHs). Endpoints were freedom from reintervention, structural valve degeneration (SVD), and infective endocarditis (IE). Propensity score matching was used to balance the comparison of PH and BJV conduits. RESULTS: The median follow-up was 6.4 years (interquartile range, IQR, 3.1-10.7 years). Freedom from reintervention at 5 and 10 years was 92% and 80%, respectively, for PH, 74% and 37% for BJV, and 75% and 47% for AH. BJV conduits had a higher risk of reintervention (P < .001) and SVD (P < .001) compared with PHs. These findings were confirmed with propensity score matching valid for conduit size >15 mm. AHs >15 mm had a higher risk of reintervention (P < .001) and SVD (P < .001) compared with PHs >15 mm. The performance of AHs and BJV conduits was similar across all sizes (reintervention, P = .94; SVD, P = .72). The incidence of IE was 1% for PH, 10% for BJV, and 1.5% for AH. CONCLUSIONS: In patients age <20 years with a conduit >15 mm, PHs outperformed BJV conduits and AHs in the pulmonary position. The performance of AH and BJV was comparable. Small conduits (≤15 mm) had similar performance across all conduit types.

Aortic valve repair in children without use of a patch.

BACKGROUND: We aimed to assess the long-term outcomes of children in whom the aortic valve could be repaired without the use of patch material. We hypothesized that if the aortic valve is of sufficiently good quality to perform repair without patches, a durable repair could be achieved. METHODS: All children (n = 102) who underwent aortic valve repair without the use of a patch between 1980 and 2016 were reviewed. RESULTS: The median patient age at operation was 2 years (interquartile range, 1 month to 9.6 years). There were 25 neonates and 17 infants. There was no operative mortality. Mean overall survival at 10 years was 97.7% ± 0.01% (95% confidence interval, [CI] 91.0%-99.4%). Forty-three patients (42.2%) required 56 aortic valve reoperations, including 24 redo aortic valve repairs, 22 Ross procedures, 8 mechanical aortic valve replacements, and 2 homograft aortic valve replacements. Mean freedom from aortic valve reoperation at 10 years was 57.4% ± 0.06% (95% CI, 44.9%-68.1%), and freedom from aortic valve replacement at 10 years was 74.5% ± 0.05% (95% CI, 63.0%-82.9%) at 10 years. Freedom from aortic valve reoperation at 10 years was 33.1% ± 0.1% (95% CI, 14.5%-53.2%) in neonates and 68.9% ± 0.06% (95% CI, 54.5%-79.6%) in older children (P < .01). CONCLUSIONS: In approximately one-third of children undergoing aortic valve repair, the repair could be achieved without patches. In these children, aortic valve repair was achieved without operative mortality. Infants and older children have low reoperation rates, whereas reoperation rates in neonates are higher. Initial repair allows valve replacement to be delayed to later in childhood, when a more durable result may be achieved.

Ross Procedures in Children With Previous Aortic Valve Surgery.

BACKGROUND: The Ross procedure in children is performed either as a primary operation, or a secondary operation after initial aortic valve surgery. OBJECTIVES: The study aimed to determine whether the outcomes of primary and secondary Ross procedure are similar. METHODS: All patients who underwent Ross procedure between 1995 and 2018 were included in the study. Outcomes were compared between those who had primary Ross procedure and those who had secondary Ross procedure, after aortic valve surgery. Propensity score matching for baseline characteristics and risk factors for death and reoperation was performed. RESULTS: Of 140 Ross procedures, 51.4% (n = 72 of 140) were primary operations, while 48.6% (n = 68 of 140) were secondary operations. Patients undergoing primary Ross procedure tended to be older (median age 8.6 years vs. 7.0 years; p = 0.10) and have a higher weight (28.9 kg vs. 19.4 kg; p = 0.07). There were no significant differences in survival or freedom from reoperation in the unmatched cohort. Propensity score matching resulted in 50 well-matched pairs. In the matched cohort, survival at 10 years was 90.0% (95% confidence interval [CI]: 77.5% to 95.7%) in the primary Ross group, compared with 96.8% (95% CI: 79.2% to 99.5%) in the secondary Ross group (p = 0.04). Freedom from autograft reoperation at 10 years was 82% (95% CI: 64.1% to 91.5%) in the primary Ross group, compared with 97.0% (95% CI: 80.4% to 99.6%) in the secondary Ross group (p = 0.03). CONCLUSIONS: Secondary Ross procedure performed after initial aortic valve surgery achieves superior long-term survival and freedom from autograft reoperation compared with primary Ross procedure. A strategy of initial aortic valve repair followed by delayed Ross procedure may provide better long-term survival and freedom from autograft reoperation.

Ross Operation in Children: 23-Year Experience From a Single Institution.

BACKGROUND: Data on the long-term outcomes in children after the Ross operation are limited. This study aimed to assess the long-term outcomes in children who underwent the Ross operation at a single institution. METHODS: The study reviewed all children (n = 140) who underwent the Ross operation at the Royal Children's Hospital in Melbourne, Australia between 1995 and 2018. RESULTS: Mean follow-up time was 8.9 years. Median age at operation was 7.4 years. The root replacement (n = 120, Ross-Konno; n = 38), root inclusion (n = 17), and subcoronary implantation (n = 3) techniques were used. Operative mortality was 5.0% (7 of 140; 3 neonates and 4 infants). There were 6 late deaths. Overall survival at 10 years was 96.2% in children older than 1 year of age and 78.9% in children younger than 1 year of age at operation (P = .003). Freedom from autograft reoperation was 86.0% at 10 years. Age younger than 1-year at operation was a risk factor for autograft reoperation (P = .02). Patients younger than 1 year of age at operation experienced a higher incidence of moderate or greater aortic insufficiency compared with patients who were older than 1 year of age (P = .006). In patients who had a poly-(p-dioxanone)-filament band placed around the sinotubular junction, freedom from moderate or greater aortic insufficiency at 10 years was 100%, compared with 83.1% in patients with no band (P = .09). CONCLUSIONS: In children older than 1 year of age, the Ross operation has excellent outcomes with no operative mortality and a low incidence of aortic insufficiency. In children younger than 1 year of age, the Ross operation is associated with higher operative mortality and a higher incidence of aortic insufficiency. Where possible, the Ross operation should be delayed beyond infancy. Poly-(p-dioxanone)-filament banding may reduce the incidence of aortic insufficiency after the Ross operation.