Is there still a place for open surgical valvotomy in the management of aortic stenosis in children? The view from Southampton

Objective: The most appropriate management of aortic stenosis (AS) in children remains controversial. The purpose of this study was to determine the outcome following open valvotomy for AS in children. Methods: Ninety-seven consecutive, unselected, children (mean age 3.2 ± 3.6 years, 1 day-15 years) underwent an open valvotomy for critical (n = 36) or severe (n = 61) AS between 1979 and 2000 in Southampton. Twenty-six were neonates (1-31 days), 27 were infants (1-12 months) and 44 were older children (1-15 years). Mean follow-up was 10 ± 5.4 years, 1 month-21.9 years. Results: Two neonates died early giving an overall operative mortality of 2.1% (7.7% for the neonates and 0% for infants and older children). The mean aortic gradient was reduced from 76 to 24.5 mmHg (P < 0.0001). Residual or recurrent AS occurred in 17 patients and severe aortic regurgitation in eight patients. Kaplan-Meier 10-year freedom from residual or recurrent AS was 83.1 ± 4.7% and from severe aortic regurgitation was 95.3 ± 2.7%. Twenty-five patients required an aortic re-operation or re-intervention, 18 of whom had an aortic valve replacement (AVR) (mean valve size 21.8 ± 0.9 mm, range 21-25 mm). Ten-year freedom from any aortic re-operation or re-intervention was 78.4 ± 5.2% and from AVR was 85.1 ± 4.6%. There were ten late deaths. Overall 10-year survival, including hospital mortality, was 90.2 ± 3.1% (69.7 ± 9.7% for the neonates, 92 ± 5.4% for the infants and 100% for older children, (P < 0.0001). Ten-year survival for children with isolated AS (n = 69) was 100% and for those with associated cardiovascular problems (n = 28) was 67.3 ± 8.9% (P < 0.0001). All survivors are in New York Heart Association functional class I. Conclusions: Open valvotomy remains the gold standard in the management of AS in neonates, infants and older children. It is associated with low operative mortality and provides lengthy freedom from recurrent AS and regurgitation. Re-operations are common but if AVR is required, implantation of an adult-sized prosthesis is usually possible. There is a late death-hazard for those with severe associated lesions, but the survival prospects for the patients with isolated AS are excellent.