Primary Treatment of Congenital Aortic Stenosis in Infants: A Comparative Analysis of Balloon Aortic Valvuloplasty and Surgical Aortic Commissurotomy

Objective To compare the efficacy and safety of balloon aortic valvuloplasty (BAV) and surgical aortic commissurotomy (SAC) as primary treatment strategies for congenital aortic stenosis in infants during the first year of life. Methods This retrospective two-center cohort study included 89 infants with congenital aortic stenosis treated between April 2015 and June 2025 at two tertiary centers. Patients were divided according to the initial intervention: BAV (n = 39) and SAC (n = 50). The primary endpoint was any repeat intervention on the aortic valve. Secondary endpoints included hospital and late mortality, recurrent hemodynamically significant aortic stenosis, and clinically significant aortic regurgitation. To reduce treatment-selection bias, propensity score matching (PSM) was performed using age, sex, body weight, body surface area, and distal aortic arch Z-score, yielding 33 matched pairs. Time-to-event outcomes were analyzed using Kaplan-Meier curves and compared with the log-rank test. Cox regression analysis was used to identify risk factors for reintervention. Results In the matched cohort, both strategies achieved initial technical success with no in-hospital deaths in either group. SAC provided superior early hemodynamic relief, with lower intraoperative peak gradient (21.0 [13.0-31.0] vs 30.0 [20.0-41.0] mm Hg; p = 0.048), lower intraoperative mean gradient (10.5 [8.0-14.0] vs 20.0 [12.0-25.0] mm Hg; p = 0.005), and lower discharge peak and mean gradients (25.0 [18.0-35.0] vs 39.0 [32.0-50.0] mm Hg, p < 0.001; and 15.0 [11.0-22.0] vs 24.0 [15.0-27.0] mm Hg, p = 0.023, respectively). However, SAC was associated with longer procedural duration, longer mechanical ventilation, longer intensive care and hospital stay, and greater need for inotropic support. During follow-up, severe aortic regurgitation developed significantly more often after BAV than after SAC (18.7% vs 0%; p = 0.012). Although the rates of reintervention and restenosis did not differ significantly in the matched cohort, Kaplan-Meier analysis showed superior freedom from reintervention after SAC at 45 months (30.5% [95% CI, 15.6%-46.9%] vs 12.3% [95% CI, 2.8%-29.3%]; log-rank p < 0.001). Freedom from restenosis was also higher after SAC (30.5% [95% CI, 15.6%-46.9%] vs 15.4% [95% CI, 3.4%-35.4%]; log-rank p = 0.039). Low body weight at the time of the initial procedure was the only independent predictor of reintervention. Conclusion In this retrospective matched cohort of infants with congenital aortic stenosis, SAC was associated with lower early residual transvalvular gradients and fewer observed cases of severe AR, but required a more invasive procedure and longer postoperative recovery. BAV provided faster recovery and remains an important option, particularly in critically ill or low-weight infants.