Strategic Challenges and Controversies in Congenital Heart Defects Involving Growth and Staging: Aortic Valve Disease and Complex Defects in Low-Weight Neonates

Management strategies for aortic valve disease and treatment of complex congenital heart defects in low-weight higher risk neonates remain challenging and are somewhat controversial. Both distinct topics bring to light the diversity in reasonable approaches, potential planned versus unplanned morbidity thereto related, and the expected and open-ended outcomes we impose on our patients. For the stenotic/insufficient aortic valve in neonates and children, surgical preference, fact, or personal philosophy may lead to attempts at repair, a Ross procedure, or replacement with a new generation bioprosthetic valve. Recent trends, results, and recommendations are reviewed and compared between the three options, pertaining to what we know, what we think we know, and what expectations the future may hold. In low-weight high-risk neonates with complex congenital defects, initial treatment strategies are evolving between complete surgical repair and staged surgical and/or interventional palliation (hybrid procedures), to achieve the highest patient survival possible, albeit at the cost of increased planned or unplanned morbidity and/or reoperations. Furthermore, patient-specific geographical variations in cardiac defects, institutional expertise, abundance or paucity of experienced manpower and its level of comfort with a given defect, may play an important role in decision making toward complete repair or staging, and the outcomes there unto pertaining. Bibliography: [1] DiBardino DJ, Shores JC, Sheth M, Taylor M, Liechty K, Salazar JD. Coordinated cardiac delivery: reducing mortality in high risk fetal cardiac lesions at the University of Mississippi Medical Center. J Miss State Med Assoc 2012;53(12):400, 403 – 404 [2] DiBardino DJ, Pasquali SK, Hirsch JC, et al. Effect of sex and race on outcome in patients undergoing congenital heart surgery: an analysis of the society of thoracic surgeons congenital heart surgery database. Ann Thorac Surg 2012;94(6):2054 – 2059, discussion 2059 – 2060 [3] Ennker IC, Albert A, Dalladaku F, Rosendahl U, Ennker J, Florath I. Midterm outcome after aortic root replacement with stentless porcine bioprostheses. Eur J Cardiothorac Surg 2011;40(2):429 – 434 [4] Charitos EI, Takkenberg JJ, Hanke T, et al. Reoperations on the pulmonary autograft and pulmonary homograft after the Ross procedure: An update on the German Dutch Ross Registry. J Thorac Cardiovasc Surg 2012;144(4):813 – 821, discussion 821 – 823 [5] d'Udekem Y, Siddiqui J, Seaman CS, et al. Long-term results of a strategy of aortic valve repair in the pediatric population. J Thorac Cardiovasc Surg 2013;145(2):461 – 467, discussion 467 – 469