Aortic root replacement in children: a word of caution about valve-sparing procedures

Abstract

Objective: Evaluate the results of various surgical procedures used for aortic root replacement in children with aortic root aneurysm.

Methods: Between 1986 and 2007, 23 children (less than 16 years of age, mean age: 8.1+/-5.1 years) underwent elective aortic root replacement for aortic root aneurysm (with associated aortic insufficiency in 10 patients). All had connective tissue defect syndromes. Nine patients underwent composite valve graft repair using a mechanical valve. Fourteen children underwent valve-sparing aortic root replacement (remodeling procedure in 11, reimplantation procedure in 3). Mean follow-up (100% complete) was 7.3+/-5.5 years (range 6 months-21 years).

Results: There was one early death (4.3%)(after valve-sparing remodeling) and no late mortality. Following valve-sparing remodeling operation (10 patients, mean follow-up: 7.8+/-3.0 years), there were 9 reoperations in 6 patients and only 5 patients retained their native aortic valve. In patients who underwent valve-sparing reimplantation operation (three patients, mean follow-up: 2.1+/-0.3 years), one underwent reoperation for endocarditis. Fifteen patients had composite valve graft replacement either as a primary operation (nine cases) or at reoperation for valve-sparing failure (six cases); mean follow-up was 8.2+/-6.2 years; there was no thrombo-embolic or hemorrhagic event and one reoperation for patient-prosthesis mismatch.

Conclusions: (1) composite valve graft aortic root replacement provides excellent long-term results in children with aortic root aneurysm due to connective tissue disorder. This remains the first choice procedure in patients with more than minimal aortic insufficiency, with distorted aortic leaflets or needing concomitant mitral valve replacement. (2) Valve-sparing remodeling surgery yields disappointing results and should probably be abandoned in the pediatric population. (3) Valve-sparing reimplantation repair may achieve superior outcome but needs further evaluation.