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Ann Thorac Surg 1995;60:125-126
© 1995 The Society of Thoracic Surgeons

Discussion

	Introduction

Top Introduction

 
See also page 122.

DR ERIC L. CEITHAML (Jacksonville, FL):

I think your study reaffirms that there is a high initial surgical mortality in critical aortic stenosis in the neonate. Because we do know that pulmonary autografts grow, do you think that there might be a place for the Ross procedure in surgical treatment of critical aortic stenosis in the neonate?

DR GAYNOR:

I think a lot of the initial mortality probably is due to the characteristics of the patient rather than the method used to relieve the obstruction. Particularly in the early years of the study, I imagine many of these children had small left ventricles that were inadequate for a two-ventricle repair. The inclusion of these patients may contribute to the high initial mortality. Although the use of the pulmonary valve to replace the aortic valve is very attractive and the results in older children and adults are very encouraging, there is not a lot of experience with neonatal use of the pulmonary autograft. So I am not sure if the initial survival would be improved by doing a bigger operation in these children. It probably would decrease the need for reintervention on the aortic valve but might not decrease the need for reintervention overall because of the need for conduit changes in the right ventricular outflow tract. I am not sure what the role of the pulmonary autograft is going to be in these patients. Perhaps some of these children should have a valvotomy, and then when they come to reintervention within 4 to 5 years that would be the optimal time for a pulmonary autograft, but I think that is still to be determined.

DR DONALD C. WATSON (Memphis, TN):

Doctor Gaynor, I congratulate you on an excellent paper. One of the important dimensions of the paper is that the end result is no different for the various modalities that you use. I would like to ask two questions regarding that. On your first intervention do you have a preferred way of intervening in these neonates? Second, one might subscribe to the theory that if there are no differences in the intervention that you used, you might pick the least expensive one to start with. Could you comment on your particular view?

DR GAYNOR:

Over the course of the study, many of the patients from the 1970s had their initial intervention at The Hospital for Sick Children and a variety of techniques were used. At one time open valvotomy with inflow occlusion commonly was performed, and then at a later time they performed mainly closed valvotomies. Currently the preferred procedure is either balloon valvuloplasty or open valvotomy on cardiopulmonary bypass, and that is similar to our feeling at Duke. I am not sure what the role of balloon valvuloplasty versus an open valvotomy is going to be in these children, but I think one of those two is probably the optimal method for the initial intervention.

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