Treatment of congenital aortic valve disease: Neonatal surgical management. Pascal Vouhé - Sick Children Hospital, Paris
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1 Treatment of congenital aortic valve disease: Neonatal surgical management Pascal Vouhé - Sick Children Hospital, Paris
2 Challenges. valvar lesions. associated lesions. status of left ventricle
3 Valvar lesions. bicuspid or unicuspid valve. rarely, tricuspid valve. usually, one normal commissure. thick dysplastic leaflets. excressent fibrous nodular tissue. size of annulus : + or - hypoplastic
4 Associated lesions. LVOT lesions - subvalvar stenosis - supravalvar stenosis. mitral stenosis (parachute mitral valve). aortic coarctation
5 Standard surgical procedure. extended commissurotomy (bicuspid). aggressive shaving of leaflets. excision of fibrous nodules. commissural reconstruction. supravalvar enlargement. ligature of PDA. complete / partial closure of ASD. coarctation repair if needed
6 Standard surgical procedure Tweddell JS et al. J Thorac Cardiovasc Surg 2005;129:551
7 Standard surgical procedure
8 Tear repair + leaflet reconstruction Dave H, Prêtre R MMCTS doi: /mmcts
9 Valvuloplasty in neonates: results early mortality Necker-Enfants Malades 1/19 (5.3%) (19 patients) EACTS database 6/71 (8.5%) (71 patients)
10 Alsoufi B et al. Eur J CardioThor Surg 2007;31:1013
11 Simple aortic valve repair : freedom from reintervention Tweddell JS et al. J Thorac Cardiovasc Surg 2005;129:551
12 Ann Thorac Surg 2006; 82: Surgical valvotomy Balloon valvotomy 36
13 * Survival 80% * Reintervention : 27% of survivors (6 Ross, 2 balloon dilatation) Agnoletti G. et al. Ann Thorac Surg 2006;82:1585
14 Agnoletti G. et al. Ann Thorac Surg 2006;82:1585
15 Challenges. valvar lesions. associated lesions. left ventricle: function and size
16 left ventricle. left ventricular dysfunction - endocardial fibroelastosis - impaired systolic / diastolic function - potentially reversible - indication for "partial" balloon dilatation. left ventricular hypoplasia
17 Necker-Enfants Malades patients 11 patients (0 death) surgical valvuloplasty 8 patients 4 patients (1 death) gentle balloon dilatation
18 left ventricular dysfunction Hraska V et al. MMCTS doi: /mmcts
19 Ross procedure in children Kadner A et al. Ann Thorac Surg 2008;8
20 Ross / Ross-Konno procedures : mortality < 1 month > 1 month Ross 2/3 1/29 Ross - Konno 2/3 0/17 Total (52 pts) 4/6 (67%) * 1/46 (2.2%) * all deaths in rescue Ross for failed dilatation Kadner A et al. Ann Thorac Surg 2008;8
21 left ventricle. left ventricular dysfunction. left ventricular hypoplasia - absence of absolute criteria for biventricular repair - univentricular approach - hybrid approach
22 cohort results individual prediction Biventricular repair Norwood pathway age < 1 month aortic valve z score < moderate fibroelastosis ascending aorta > 8 mm LV length z score < - 1 Lofland GK et al. J Thorac Cardiovasc Surg 2001;121:10
23 hybrid approach. initial procedure - bilateral PA banding - duct stenting - balloon aortic valvuloplasty - ASD size calibration. "buys" time for improvement. allows delayed decision-making
24 Conclusions 1. subnormal LV function and size (most patients) - surgical valvuloplasty provides excellent results - there is no place for balloon dilatation 2. severe LV dysfunction - "gentle" balloon dilatation - followed by surgical valvuloplasty or Ross-Konno 3. LV hypoplasia - individualized management - potential place for hybrid approach.
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