Pediatric Aortic Valve Repair – Reproducible Using Adult Concepts

OBJECTIVE: Aortic valve(AV) repair and valve-preserving surgery(VPS) have evolved mainly for adults; limited data is available for pediatric patients. We have applied adult principles established in the pediatric age group. The objective was to analyze early and long-term results of AV repair in pediatric patients. METHODS: Between 1999 and 2023, 122 patients <18years(78%male; mean age 11±5years) underwent isolated AV repair(n=102;84%) or VPS(n=20;16%). The valve morphology was unicuspid(n=71;58%), bicuspid(n=21;18%), or tricuspid(n=30;24%). Eighteen patients(15%) had previously undergone a cardiac operation or balloon valvuloplasty(n=28;23%). Median follow-up was 11.3years(1week to 27years); it was 95% complete(1490 patient-years). RESULTS: Intraoperative measurement of valve configuration was performed in 90(73%) patients. Cusp plication was performed in 70(57%) patients; patch material was used in 89(73%) cases. One patient died in hospital;two died late with an overall survival of 98% at 20years. Thirty-six required AV reoperation after VPS(n=1) or AV repair(n=35). Freedom from AV reoperation at 20years was 50% after isolated valve repair and 92% after root repair(p=0.024); it was 40% in unicuspid, 93% in bicuspid, and 87% in tricuspid aortic valves(p=0.002). Unicuspid morphology((p=0.011;HR 4.6;CI 95% 1.41 to 15.13) was predictive for reoperation. Cusp plication(p=0.023;HR 0.79; 95%CI 0.13-0.97) was associated with better durability;VPS(p=0.054;HR 0.14; 95%CI 0.02-1.03) was associated with a trend to lower reoperation. CONCLUSION: Pediatric AV repair can be performed with good results using established techniques of adult AV repair. The durability of bicuspid and tricuspid AVs is excellent, that of unicuspid repair is limited by the durability of the patch material required. Repair should be the primary approach for all pediatric AVs.