Ann Thorac Surg 2005;79:51-52
© 2005 The Society of Thoracic Surgeons
INVITED COMMENTARY
James Monro, FRCS
Department of Cardiac Surgery, Southampton General Hospital, Tremona Rd, Mailpoint 46, Southampton SO16 6YD, UK
monro1711{at}aol.com
As with so many things in life, the outcome depends on what you start with. Young infants with aortic stenosis most commonly have bicuspid valves with cuspal fusion, or the valves may be tricuspid or even monocuspid. A perfect result is unlikely to be achieved with any intervention. This interesting article from Padova describes 40 infants who had balloon valvotomy in a 13-year period. Of the 38 survivors, 11 required aortic valve surgery (with good results) within a mean of 7 months and 8 within 1 year. A further 7 patients had repeat ballooning. This compares unfavorably with the best reports of open surgical valvotomy in neonates, where freedom from reoperation on the aortic valve has been reported as 85% and 50% at 5 and 10 years, respectively. It is not surprising that a longer-lasting result can be achieved by direct surgical intervention, where exact splitting of fused commissures and shaving off of obstructing nodules can produce the maximum valve orifice without causing regurgitation.
Ballooning has become the method of choice in most units throughout the world. However, the devastating results of a torn leaflet causing early severe regurgitation will require emergency surgery. It may not be possible to repair the valve, and the only realistic treatment is a Ross procedure. Therefore, all balloonists should have surgical backup with surgeons experienced with the Ross procedure. It is interesting that of the 11 patients in this series, only 2 had torn leaflets; the others mostly had residual stenosis. This would suggest that the cardiologists erred on the side of caution—and a good thing too. It is clear that all infants who undergo ballooning or surgery will need further procedures on the aortic valve, and it is important that the parents understand this. Ballooning is relatively safe and simple, but reintervention will be needed sooner than after direct surgical valvotomy. This report shows that the defects of nearly half of those who undergo operation can be repaired and that the others need a Ross procedure. The authors sensibly state that patients are better off with their own valves, providing that they work well. The only way to determine whether early ballooning or direct surgical valvotomy produces the better long-term outcome is to perform a multicenter controlled trial with at least 15 years of follow-up.
Related Article
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Critical Aortic Stenosis in Early Infancy: Surgical Treatment for Residual Lesions After Balloon Dilation
- Vladimiro L. Vida, Tomaso Bottio, Ornella Milanesi, Elena Reffo, Roberta Biffanti, Raffaele Bonato, and Giovanni Stellin
Ann. Thorac. Surg. 2005 79: 47-51.
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