Trajectory of Left Ventricular Remodeling in Children With Valvar Aortic Stenosis Following Balloon Aortic Valvuloplasty

Abstract

Background: Aortic valve stenosis is the most common type of congenital left ventricular (LV) outflow tract obstruction. Balloon aortic valvuloplasty (BAV) has become the first-line treatment pathway in many centers. Our aim was to assess the trajectory of LV remodeling following BAV in children and its relationship to residual aortic stenosis (AS) and insufficiency (AI). Methods: Children <18 years of age who underwent BAV for isolated aortic stenosis from 2004 to 2012 were eligible for inclusion. Those with AI before BAV, other complex congenital heart lesions, or <2 accessible follow-up echocardiograms were excluded. Baseline and serial echocardiographic data pertaining to aortic valve and LV size and function were retrospectively collected through December 2017 or the first reintervention. Longitudinal data was assessed using per-patient time profiles with superimposed trend lines using locally estimated scatterplot smoothing. Associations with reintervention or death were also evaluated. Results: Among the 98 enrolled children, the median (interquartile range) age at BAV was 2.8 months (0.2–75). The median (interquartile range) follow-up was 6.8 years (1.9–9.0). Children with predominantly residual AI (n=11) demonstrated progressive increases in their LV end-diastolic dimension Z score within the first 3 years after the BAV, followed by a plateau ( P <0.001). Their mean LV circumferential and longitudinal strain values remained within the normal range but lower than in the non-AI group ( P <0.001 and P =0.001, respectively). Children with predominantly residual aortic stenosis (n=44) had no changes in LV dimensions but had a rapid early increase in mean LV circumferential and longitudinal strain. The cumulative proportion (95% CI) of reintervention at 5 years following BAV was 33.7% (23.6%–42.4%). Conclusions: Our study demonstrates that LV remodeling occurs mainly during the first 3 years in children with predominantly residual AI after BAV, with no subsequent significant functional changes over the medium term. These data improve our understanding of expected patient trajectories and thus may inform decisions on the timing of reintervention.

Long‐Term Results of Congenital Aortic Stenosis Treatment in the Era of Percutaneous Balloon Valvuloplasty: Up to 33 Years Follow‐Up

“…In a meta‐analysis by Hill et al, 16 survival, freedom from valve replacement, and freedom from reintervention at 10 years were 87%, 76%, and 46%, respectively, as compared with 89.9%, 85.9%, and 59.9% in our study. Also, the above‐mentioned study of Papneja et al 15 demonstrated a 10‐year reintervention‐free survival of 55%. Our survival analysis shows a significant difference between patients who required the BVPL in the neonatal period and those treated later.…”

“…A recent study in neonates and children by Papneja et al 15 showed that well‐preserved LV function before the BVPL and a larger aortic valve annulus are associated with a lower risk of reintervention. The authors point out that this finding contrasts with previous studies, where a larger annulus was associated with a higher risk for developing aortic regurgitation, and speculate about the role of contemporary approach to use smaller balloons in children with larger annuli.…”