Central Message
Aortic valve reconstruction can be an option as a bridge to definitive management in selected children with aortic valve disease.
Complex aortic valve pathology.
See Article page 1180.
Management of significant aortic valve disease in children remains a significant challenge, largely due to a number of factors, including concomitant presence of associated lesions requiring intervention, lack of an appropriate-size prosthesis, lack of growth potential, and the desire to avoid anticoagulation. In this scenario, the use of a pulmonary autograft in the aortic position (Ross procedure) has become a common and effective option to relieve significant stenosis and/or regurgitation, particularly in the smallest patients, albeit at the price of reconstruction of the pathway between the right ventricle and the pulmonary artery and the associated need for recurrent reinterventions. Alternatively, complex aortic valve repair with pericardial reconstruction is being increasingly used in some centers as an alternative to avoid the creation of a “double valve” condition.
Acknowledging that the ultimate goal is the preservation of left ventricular function with the least number of reinterventions, neither approach provides a final and reintervention-free solution; hence the question about the durability of each management strategy.
Despite its inherent technical challenges, it seems obvious that the Ross procedure would be preferred for a number of practical reasons, including applicability to the smallest patients, avoidance of anticoagulation, ability to provide the necessary size matching for a given patient size, and avoidance of growth restriction over time. On the other hand, older children with a larger annulus may be amenable to repair and reconstruction with autologous pericardium, providing a midterm solution and potentially a bridge to a conventional aortic valve replacement at a later date, thereby avoiding a more complex procedure, the need for anticoagulation at a younger age, and the creation of a “two-valve condition”. Therefore, the real debate centers on the choice between aortic valve repair or replacement with a pulmonary autograft in older children.
In their article in this issue of the Journal, Danial and colleagues
1
aim to provide some perspective on this controversy by a propensity-matched comparison of 34 patients undergoing either a complex aortic valve repair or a Ross procedure beyond neonatal age. Although there was no difference in operative mortality between the 2 groups, mortality during follow-up was higher in the Ross group. Perhaps not surprising, considering that all these deaths occurred in patients with Shone's anomaly, concomitant interventions at the time of the index procedure and a large proportion of interventions undertaken on an emergency basis. Nevertheless, when it comes to the effectiveness in addressing the primary issue, the freedom from reintervention on the left ventricular outflow tract was substantially lower in the valvuloplasty cohort.These observations reaffirm the idea that aortic valvuloplasty can provide a suitable interim solution for those patients who in light of their anatomy and size afford the option of avoiding an aortic valve replacement with pulmonary autograft while allowing for growth of the annulus, avoidance of anticoagulation, and an understanding that the systemic valve issue is not resolved and that this is a bridge to a future valve replacement. In the meantime, the durability of this approach perhaps could be enhanced by appropriate patient selection and use of more suitable reconstruction materials. The jury is still out.
Reference
- Ross procedure or complex aortic valve repair using pericardium in children: a real dilemma.J Thorac Cardiovasc Surg. 2022; 163: 1180-1191.e6
Article info
Publication history
Published online: March 24, 2021
Accepted:
March 18,
2021
Received in revised form:
March 18,
2021
Received:
March 18,
2021
Footnotes
Disclosures: The author reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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© 2021 by The American Association for Thoracic Surgery
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- Ross procedure or complex aortic valve repair using pericardium in children: A real dilemmaThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3
- PreviewDifficult to repair aortic valve lesions, requiring the use of a valve substitute, remain controversial in the face of the Ross procedure, despite undeniable technical advances. This study was undertaken to compare midterm outcomes of children treated using the Ross procedure or aortic valvuloplasty for complex aortic valve lesions.
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