Long-term postoperative follow-up in surgery for congenital aortic valvular stenosis.

Abstract

Twenty-three children with congenital aortic valvular stenosis have undergone operation prior to November 1964, without a hospital mortality. A 4-week-old infant who died at the induction of anesthesia is not included. There was one late death due to uncontrolled aortic regurgitation. The late death occurred at the time of the second operation for placement of aortic valve prosthesis in another institution. Thirteen of the 23 patients have an audible postoperative diastolic murmur. In two this murmur was present preoperatively. Eight of the 13 are considered to have mild aortic regurgitation, four moderate, and one severe. Of the 18 patients with competent valves or mild regurgitation, all have normal electrocardiograms. Ten of these 18 patients had electrocardiographic evidence of left ventricular hypertrophy before surgery. Four of the five patients with moderate or severe regurgitation have electrocardiographic evidence of left ventricular hypertrophy. These patients have all been followed from 3 to 5½ years. There is no evidence that the amount of regurgitation has either decreased or increased since surgery. The gradients measured at cardiac catheterization before operation range from 138 to 56 mm. Hg, with an average of 89 mm. Postoperatively, these gradients ranged from 45 to zero, with an average of 27. Pressures measured at the time of operation before and after valvulotomy agree favorably with the pressures measured at the time of cardiac catheterization before and after valvulotomy. The development of postoperative regurgitation was found to be related to the incision of a rudimentary raphe which made an anatomically bicuspid valve tricuspid. It is also related to the position of the patient in the series, the regurgitation occurring most frequently in the first half of the series. Comparison with another series with a high residual gradient, but a lower incidence of the severity of regurgitation, suggests that the optimal gradient reduction may be purchased at the expense of an unavoidable amount of aortic regurgitation. This aortic regurgitation, however, is not necessarily hemodynamically significant.