Neonatal Isolated Critical Aortic Valve Stenosis: Balloon Valvuloplasty or Surgical Valvotomy

Background

Open surgical valvotomy and transcatheter balloon valvuloplasty are recognised treatments for neonatal critical aortic stenosis.

Methods

A retrospective analysis was undertaken of all newborns with critical aortic valve stenosis between 1990 and 2000 presenting to a tertiary centre and who required intervention. The initial catheter and surgical intervention was generally based on the preference of the attending cardiologist and the anatomy of the aortic valve and in consultation with the cardiothoracic surgeon. The two groups were therefore not strictly comparable. Twelve were subjected to balloon valvuloplasty and thirteen to surgical valvotomy at a median age of 11 days (2–42 days) and 3.5 days (1–19 days) respectively. There was no significant difference in the timing of the procedure, weight of the infant, aortic annulus or left ventricular dimensions in either group.

Results

There was one unrelated hospital death in the balloon group compared to two in the surgical group both of whom had endocardial fibroelastosis. Mild to moderate aortic regurgitation was seen after both procedures. Four patients in the balloon valvuloplasty group, developed femoral artery thrombosis and two had cardiac perforation that resolved with non operative management. The mean Doppler gradient was reduced from 44 ± 14 mmHg to 13.4 ± 5 mmHg (p < 0.01) in the valvuloplasty group compared to a reduction from 42 ± 15 mmHg to 27 ± 8 mmHg (p < 0.05) in the surgical group. Five patients in the balloon group required re-intervention within 3 weeks to 21 months after the initial procedure. Two patients in the surgical group required a pulmonary autograft and Konno Procedure 3 and 5 years following surgical valvotomy.

Conclusion

Both aortic valvulopasty and valvotomy offered effective short and medium term palliation. Balloon valvuloplasty patients had a higher re-intervention rate but shorter hospital and intensive care stay, reduced immediate morbidity and were associated with less severe aortic regurgitation.

Introduction

Neonatal critical aortic stenosis is potentially life threatening with a high morbidity and significant mortality despite early intervention.1, 2, 3, 4, 5, 6, 7 It is uncommon and accounts for 1–3% of neonates with significant congenital heart disease.³ Infants may present in cardiac failure and/or in a low output state, many requiring ventilation, inotropic support and prostaglandin E1 infusion, the latter to maintain patency of the arterial duct to assist systemic circulation.² Cross-sectional echocardiography is able to define the diagnosis accurately and determine other abnormalities.¹ Open surgical valvotomy and transcatheter balloon valvuloplasty of the aortic valve are recognized treatment modalities with favorable results.8, 9 A neonatal Ross procedure has been advocated by some authors.¹⁰

Previous comparisons of the outcome of balloon valvuloplasty and surgical valvotomy have been published though the numbers were limited, not randomized or from different time periods.8, 9 Other series of critical aortic valve stenosis have included additional malformations with outcomes focussed on predicting mortality arising from multiple anatomical variables.1, 2

The purpose of this study was to compare the short and medium term outcome of neonates with isolated critical aortic stenosis who required intervention during the same time period at a single tertiary institution, to determine their immediate morbidity, the re-stenosis rate and the need for re-intervention. Their duration of hospitalization and intensive care stay were also determined. The procedure selected depended on the preference of the attending cardiologist after discussion with the attending cardiac surgeon, and taking into account the anatomy of the aortic valve. The two groups were therefore not comparable, the surgical group including somewhat sicker infants.