Critical aortic stenosis in neonates: Balloon valvuloplasty versus surgical valvotomy

Abstract

Congenital aortic valvular stenosis in neonates is a life-threatening condition requiring urgent management. Therapeutic strategy remains controversial between balloon valvuloplasty (BV) and surgical valvulotomy (SV). We reviewed our long-term single-center experience of neonatal aortic stenosis management and compared aortic valve outcomes regarding BV versus SV. Between 1990 and 2020, 137 patients underwent aortic stenosis treatment (SV [ n = 83] and BV [ n = 54]) with a median age of 5.5 days (range: 0 to 30 days) and a median weight of 3 kg (range: 1.8 to 4.8 kg). Procedure strategy was decided according to the surgeon availability especially at the beginning of the study. Additionally, there was a traditional local protocol favoring balloon in case of left ventricular dysfunction like in many centers. The median follow-up was 6.7 years (up to 28y, 88% complete). We did not report any operative death but the intra-hospital mortality was notably greater for patients after balloon procedure (20.3%) versus SV group (8.4%). The one-year and ten-year patient survival was respectively 90 and 89% in SV group versus 75 and 69% in BV group ( P < 0.005). In our cohort, 77 patients underwent reoperation for persistent aortic stenosis. Most of the patients after BV ( n = 38, 70%) required a reintervention. The median age for reintervention was 2.9 years in the SV group versus 0.3 years for patients in the BV group. Associated intracardiac lesions and the initial valvuloplasty procedure were significantly associated with the risk of reoperation independently of the maximal gradient and the aortic annulus size. Ten-year freedom from reintervention for SV and BV group were respectively 53% and 35% ( P < 0.005, Fig. 1 ). Long-term survival and freedom from reintervention are excellent after surgical valvotomy. However, poor results are obtained when patients had initial left ventricular dysfunction or multiple left ventricular outflow lesions.