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Management Of Critical Left Ventricular Outflow Obstruction In Children Under One Year Of Age
B. L. Reemtsen, C. John, D. Nath, J. Pruetz, W. J. Wells*, V. A. Starnes*. Children's Hospital Los Angeles, Los Angeles, CA,
BACKGROUND:
Neonates and infants with critical left ventricular outflow tract obstruction (LVOTO) present a difficult surgical challenge due to the need of aortic valve replacement. Mechanical prosthesis are often too large, with the added disadvantage of anticoagulation in the young. Small homografts have extremely limited durability in the aortic position. The aortic valve replacement of choice in our institution is the pulmonary autograft. We feel the potential advantages of the autograft, namely excellent size matching, unmatched durability, lack of anticoagulation and potential for growth, makes this the aortic valve replacement of choice in this age group.
METHODS:
Between ’93 and ’07 there were 37 patients that required intervention for LVOTO with aortic valve replacement under 1 yr of age (mean age 3.9 mo.) with 8 (22%) being less than 30 days. All had critical aortic stenosis (AS) and in 7 (19%) there was also important aortic insufficiency (AI). Associated defects included interrupted aortic arch/ventricular septal defect (IAA/VSD) (7), important mitral valve (MV) stenosis (Shone’s complex) (9), coarctation of the aorta (CoAo) (3), and discrete subaortic stenosis (3). Interventions prior to the autograft placement were percutaneous aortic valvotomy (16), surgical aortic valvotomy (4), IAA/VSD repair (5), CoAo repair (2), MV repair (1).
RESULTS:
In this complex group of neonates and infants the Ross procedure was combined with a Konno LVOT augmentation in 14 (38%), MV repair in 6 (16%), IAA/VSD repair in 2, and repair CoAo in 1. Overall mortality was 9 of 37 (24%) with 7 hospital (19%) and 2 late (5%) deaths. Three independent predictors of mortality were observed. First surgical intervention during the neonatal period carried a 50% (4/8) mortality. Next, anatomic features such as IAA/VSD (3/7=43%) or concomitant mitral valve anomalies (3/6=50%) had predictably higher death rates.
Among 28 intermediate term survivors (median follow-up 6.5 yrs, range = 0.5-14.0 yrs) there have been 2 autograft reinterventions including one annuloplasty repair (8 yrs post Ross) and one prosthetic replacement (2.6 yrs). Pulmonary homograft replacement has been performed in 10/28 (36%) at a mean interval of 3.9 yrs. We have observed the growth of the autograft has followed the normal z value curve for a native pulmonary valve.
CONCLUSIONS:
In neonates and infants with critical LVOTO the conduit of choice for aortic valve replacement is the pulmonary autograft. The durability of the autograft compares favorably to a mechanical valve without the need for anticoagulation. The prosthesis match and the growth potential makes the autograft the ideal valve substitute in the very young.
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