Aortic Valve Replacement in Neonates and Infants: An Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

Study Questions:

What are the early outcomes of aortic valve replacement in neonates and infants across a multicenter cohort?

Methods:

A retrospective review of neonates (<30 days) and infants (30 days to 1 year) in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database was performed. Patients were included if they had undergone aortic valve replacement with the Ross-Konno procedure, Ross procedure, or homograft between 2000 and 2009. Patients with common arterial trunk were excluded. Preoperative characteristics, operative data, and early outcomes were reported.

Results:

A total of 160 patients (43 neonates and 117 infants) were included in the analysis. Concomitant arch repair was performed in 19% of patients, and mitral valve surgery was performed in 12% of patients. Postoperative mechanical circulatory support was required in 11% of patients. Overall in-hospital mortality was 18%, with in-hospital mortality of 28% for neonates. Patients undergoing homograft aortic valve replacement had the highest in-hospital mortality at 40%. Concomitant aortic arch repair was associated with a higher in-hospital mortality (33% vs. 15%, p = 0.02), whereas concurrent mitral valve surgery was not (21% vs. 18%, p = 0.73).

Conclusions:

Aortic valve replacement is a high-risk procedure in infants and children. The requirement for concomitant arch repair increases surgical risk.

Perspective:

Neonates and infants with aortic stenosis requiring early intervention represent a high-risk patient population. This study demonstrates significant in-hospital mortality rates (28%) overall for neonates undergoing aortic valve replacement. This risk is higher than other common, high-risk neonatal surgeries (such as the Norwood procedure). The reasons for increased mortality in patients undergoing homograft aortic valve replacement were not identified by this study. Potential etiologies include selection bias (sicker patients undergoing homograft replacement) or the possibility of differing surgeon or center capabilities. Neonates and infants requiring aortic replacement constitute a particularly difficult population to study. Individual centers do not perform large numbers of aortic valve replacements, and outcomes may be impacted by complex factors related to patient selection and the suitability of individuals for biventricular repair. It will be interesting to follow this cohort of patients into the future to assess their need for additional procedures, particularly aortic root replacements and right ventricle-to-pulmonary artery conduit replacements.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD & Pediatrics, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Interventions

Keywords: Infant, Heart Valve Prosthesis, Transplantation, Thoracic Surgery, Pulmonary Artery, Heart Diseases, Bioprosthesis, Cardiac Surgical Procedures, Heart Ventricles, Thiazolidinediones


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