National Practice Patterns and Early Outcomes of Aortic Valve Replacement in Children and Teens

Aims To support decision-making in children undergoing aortic valve replacement (AVR), by providing a comprehensive overview of published outcomes after paediatric AVR, and microsimulation-based age-specific estimates of outcome with different valve substitutes. Methods and results A systematic review of published literature reporting clinical outcome after paediatric AVR (mean age <18 years) published between 1/1/1990 and 11/08/2021 was conducted. Publications reporting outcome after paediatric Ross procedure, mechanical AVR (mAVR), homograft AVR (hAVR), and/or bioprosthetic AVR were considered for inclusion. Early risks (<30d), late event rates (>30d) and time-to-event data were pooled and entered into a microsimulation model. Sixty-eight studies, of which one prospective and 67 retrospective cohort studies, were included, encompassing a total of 5259 patients (37 435 patient-years; median follow-up: 5.9 years; range 1–21 years). Pooled mean age for the Ross procedure, mAVR, and hAVR was 9.2 ± 5.6, 13.0 ± 3.4, and 8.4 ± 5.4 years, respectively. Pooled early mortality for the Ross procedure, mAVR, and hAVR was 3.7% (95% CI, 3.0%–4.7%), 7.0% (5.1%–9.6%), and 10.6% (6.6%–17.0%), respectively, and late mortality rate was 0.5%/year (0.4%–0.7%/year), 1.0%/year (0.6%–1.5%/year), and 1.4%/year (0.8%–2.5%/year), respectively. Microsimulation-based mean life-expectancy in the first 20 years was 18.9 years (18.6–19.1 years) after Ross (relative life-expectancy: 94.8%) and 17.0 years (16.5–17.6 years) after mAVR (relative life-expectancy: 86.3%). Microsimulation-based 20-year risk of aortic valve reintervention was 42.0% (95% CI: 39.6%–44.6%) after Ross and 17.8% (95% CI: 17.0%–19.4%) after mAVR. Conclusion Results of paediatric AVR are currently suboptimal with substantial mortality especially in the very young with considerable reintervention hazards for all valve substitutes, but the Ross procedure provides a survival benefit over mAVR. Pros and cons of substitutes should be carefully weighed during paediatric valve selection.

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“…Nelson et al recently reported early mortality comparable to the current review in 3446 children undergoing AVR. 36 …”

Section: Discussionmentioning

confidence: 99%

Paediatric aortic valve replacement: a meta-analysis and microsimulation study

Notenboom

Schuermans

Etnel

et al. 2023

European Heart Journal

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“…In the recent database study of 3446 children who underwent aortic valve replacement, Nelson and colleagues 23 demonstrated that children who underwent aortic valve replacement with a homograft had the highest early mortality. No late mortality or reoperation rate was reported in this large database study.…”

Section: Comparative Studiesmentioning

confidence: 99%

Aortic valve surgery in children

Buratto

Konstantinov

2021

The Journal of Thoracic and Cardiovascular Surgery

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The ideal aortic valve surgery in children must result in an unobstructed, competent aortic valve that is also durable and accommodates growth of the child. Intuitively, aortic valve surgery in children must emulate native aortic valve anatomy and physiology as close as possible, preferably using autologous tissues with growth potential. The optimal approach to aortic valve surgery in children is yet to be defined. The purpose of this focused review is to highlight recent key publications on the topic. AORTIC VALVE REPAIRAortic valve repair is currently performed in children with increasingly good results. 1 Last year, outstanding results of aortic valve repair in neonates were reported by Vergnat and colleagues 2 in neonates with congenital aortic stenosis treated between 1989 and 2015. Of these patients, 52 underwent surgical aortic valve repair and 51 underwent balloon aortic dilatation. There was similar early mortality (7.8% for ballooning vs 3.9% for repair) and 10-year survival (88% for ballooning vs 94% for surgery, P ¼ .25). However, freedom from reoperation was superior in the group undergoing aortic valve repair (66% vs 36%, P < .01). Similar results have been reported by Siddiqui and colleagues 3 for neonates and infants. Thus, it appears that the outcomes of aortic valve repair in neonates and infants are superior to those achieved by balloon dilation.In children aged more than 1 year, the operative mortality for aortic valve repair is 0.4% to 1.8% and freedom from reoperation is approximately 70% at 10 years. 4 d'Udekem and colleagues 5 reported 142 children who underwent aortic valve repairs between 1996 and 2009 at a median age of 9 years. Early mortality was 1.8% in children aged more than 1 year. Freedom from reoperation was 80% at 7 years follow-up. The use of cusp extension was associated with increased risk of reoperation.

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“…[45][46][47] Surgical Valve Replacement in the CHD Patient Mechanical valves are preferred for mitral and AoV replacement in patients younger than 50 years, because they have improved longevity and better hemodynamics in smaller valve sizes. [48][49][50][51][52][53][54] Conversely, mechanical valves do not perform as well in the right heart due to an increased incidence of thrombotic complications. 41 Most pediatric surgeons recommend bioprosthetic valves in the tricuspid and pulmonary positions and mechanical valves in the mitral position and either a mechanical valve or, less commonly, an autograft valve in the aortic position (Ross procedure).…”

Section: Tricuspid Valve Diseasementioning

confidence: 99%