[Aortic valve stenosis in children. Surgical valvuloplasty long-term results]. / Sténose valvulaire aortique chez l'enfant. Résultats à long terme de la valvuloplastie chirurgicale.

From 1960 through 1992, 67 children with congenital aortic stenosis aged 6-228 months (M 105.7 +/- 52) were submitted to aortic valvuloplasty at our institution. There was no hospital mortality. During the follow-up of 127.5 +/- 66.7 months, there were two late valve related deaths. Eight patients (11.9%) developed aortic regurgitation 5 to 125 months (M 66.6 +/- 35) following surgical valvuloplasty and one of them required aortic valve replacement. Because of restenosis, 15 patients required a second operation. Of them five children underwent a second aortic valvuloplasty without mortality and, in four of them, the functional result has been excellent after a mean follow-up of 75.4 +/- 12 months. Ten patients required an aortic valve replacement 62 to 208 months post-op (M 100.9 +/- 50.8). Mechanical prosthesis were used in 6 and bioprosthesis in 4. Two patients required a Konno and one patient a Ross procedure. There were no early nor late deaths following reoperations. The 20 year survival rate following the first valvuloplasty was 94%, the freedom from reoperation 63% and the freedom from aortic valve replacement 73% for the same time period. Our results demonstrate that congenital aortic valvar stenosis in children can be surgically well controlled until adulthood. Our study also illustrates that surgical valvuloplasty is a safe and efficacious procedure and that its beneficial effect is maintained over 20 years in the majority of children.

[Ebstein's anomaly: valvular replacement in pediatric patients]. / Maladie d'Ebstein: remplacement valvulaire à l'âge pédiatrique.

The surgical treatment of Ebstein's anomaly is still controversial. Therefore we have retrospectively studied the results of tricuspid valve replacement (TVR) performed for this anomaly at Sainte Justine Hospital. From October 1977 to December 1997, 9 patients with Ebstein's anomaly, aged from 31 to 248 months (mean 176 +/- 66), have undergone TVR. Eight children were in functional class III or IV (NYHA), while one was in class II. Seven patients underwent plication of the atrialized right ventricular segment. Eight bioprostheses (ranging in diameter from 31 to 35 mm) and one mechanical prosthesis (21 mm) were used. The valve was implanted on the tricuspid annulus in six cases. There was no operative death, nor postoperative complete heart block. Follow-up ranged from 11 to 264 months (mean 91 +/- 84). One late death occurred unrelated to surgery. The probability of 20 years survival is 88%. One patient required a second TVR 162 months after the first surgery because of bioprosthesis failure. Seven of the surviving patients are in functional class I, while one patient is in class II. This experience suggests that TVR with bioprosthesis is a good therapeutical option for children with Ebstein's anomaly since the operative risk is low, the functional status improved in all patients and the durability of bioprosthesis in tricuspid position has been good.

Long-term results of surgical valvuloplasty for congenital valvar aortic stenosis in children.

BACKGROUND: To question the validity of surgical aortic valvuloplasty for congenital aortic valve stenosis, a retrospective study was undertaken to determine the long-term survival, the incidence of valve restenosis or insufficiency, and the freedom of reoperation or valve replacement. METHODS: From January 1960 through 1992, 67 consecutive children diagnosed with congenital aortic valve stenosis underwent an open aortic valvuloplasty at our institution. Ages at operation ranged from 6 to 228 months (mean 105.7 +/- 52 months). The mean follow-up of these patients has been 127.5 +/- 66.7 months. RESULTS: There was no hospital mortality, but two late valve-related deaths occurred. Eight patients developed aortic regurgitation 5 to 125 months (mean 66.6 +/- 35 months) after surgical valvuloplasty, and 1 of them required aortic valve replacement. Because of restenosis, 16 patients required a second operation. Of them, 5 children underwent a second aortic valvuloplasty without mortality and, in 4 of them, the functional result has been excellent after a mean follow-up of 75.4 +/- 12 months. Eleven patients required an aortic valve replacement 62 to 208 months postop (mean 100.9 +/- 50.8 months). Mechanical prosthesis were used in 7 and bioprosthesis in 4. Two patients required a Konno and 1 required a Ross procedure. There were no early nor late deaths after reoperations. The probability of 20-year survival after the first valvuloplasty was 94%, the freedom of reoperation 63%, and the freedom of aortic valve replacement 73% for the same time period. CONCLUSIONS: Our results demonstrate that congenital aortic valvar stenosis in children can be surgically well controlled until adulthood. Our study also shows that surgical valvuloplasty is a safe and efficacious procedure and that its beneficial effect is maintained over 20 years in the majority of children.

[Pulmonary valve replacement in children]. / Remplacement valvulaire pulmonaire chez l'enfant.

From February 1988 to October 1994, 15 pulmonary valve replacements (PVR) have been performed at St-Justine Hospital in children with a mean age of 145.7 months. Ten children previously had a correction of tetralogy of Fallot; two had absent pulmonary valve syndrome; one had been operated on for pulmonary atresia with intact ventricular septum, one other had a correction for a ventricular septal defect with pulmonary artery banding; the last patient developed degeneration of a pulmonary bioprosthesis. The time between the primary repair and the PVR ranged from 61 to 221 months. Fourteen bioprosthesis and one aortic homograft were implanted. All patients had antiplatelet treatment. There was one operative death due to a fatal anaphylactic reaction and one late death occurred unrelated to valvular surgery. At follow-up from 1 to 187 months (mean, 40.7 months) all patients were in New York Heart Association Class 1. No hemorrhagic nor thromboembolic complication have been observed and no reoperation for bioprosthesis failure was necessary. Nevertheless in subsequent echocardiographic studies, two patients with the smallest bioprosthesis (21 mm) have developed pulmonary gradients of 80 and 85 mmHg, 65 and 80 months following PVR. While our results with PVR in children have been satisfactory, this operation should be performed only in symptomatic patients with severe pulmonary regurgitation because of progressive deterioration of the available bioprosthesis.

[Aortic valve replacement in children]. / Remplacement valvulaire aortique chez l'enfant.

From January 1970 to January 1993, 47 aortic valve replacements have been performed in children aged 166.8 +/- 50 months. The valvular pathology was congenital in 39 patients and associated cardiac anomalies were present in 31 cases. 30 children had a previous surgical procedure on the aortic outflow. Seven bioprosthesis and 40 mechanical valves have been implanted. At the time of surgery, an additional major cardiac correction has been performed on 17 occasions (Konno, Bentall, Fontan, correction of truncus arteriosus etc.). While no death occurred in the group subjected only to aortic valve replacement, 7 of the 17 patients where a major cardiac procedure was added died. During a mean follow-up of 61.2 +/- 59.1 months, 3 late deaths occurred, 2 of them non related to valvular surgery. Three reoperations have been performed, in two instances for replacing a degenerated bioprosthesis. One thromboembolic event occurred as well as one temporary episode of haemolytic anaemia. No haemorrhagic complication has been observed. While the results of isolated aortic valve replacement in children are excellent, the risk for hospital death is increased substantially when a major cardiovascular procedure is added to valve replacement, and because of rapid deterioration, the heterografts are now contra-indicated in children.