Section of Cardiothoracic Surgery and Pediatric Cardiology, James W. Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA.
Ann Thorac Surg. 2012 Jul;94(1):146-53; discussion 153-5. doi: 10.1016/j.athoracsur.2012.02.054. Epub 2012 Apr 25.
For children with congenital aortic stenosis (AS) who are selected for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter balloon aortic dilation (BAD). A retrospective study was undertaken to compare the effectiveness of BAD versus SAV, evaluating the long-term survival, incidence of aortic valve restenosis or aortic insufficiency (AI) or both, and freedom from reoperation for repeated valve repair or replacement. Neonates less than 2 months of age were excluded from this comparison.
We reviewed the outcomes of children undergoing repair by SAV (n = 89) and BAD (n = 69) at our institution during a recent 20-year period. Clinical and echocardiographic follow-up were analyzed. The patient groups were compared with regard to the persistence or recurrence of postoperative aortic gradients and valve insufficiency and valve-related reintervention, including aortic valve replacement (AVR).
There was no significant difference between the groups with respect to mean age, body surface area, valve anatomy, sex, and preoperative gradients. Our data demonstrate that gradient reduction, AI, and the need for reintervention were worse for BAD. Aortic gradients at last follow-up were similar in both cohorts, but return of a significant gradient occurred sooner for patients who had BAD. Aortic gradient at discharge was significantly better for the patients who underwent SAV. Kaplan-Meier analysis showed that at 10 years, comparison of SAV and BAD was as follows: freedom from reintervention, 72% versus 53% (p = 0.02) and freedom from AVR, 80% versus 75% (p = 0.32).
BAD yields less gradient reduction, more postprocedural AI, and a shorter interval between initial and subsequent reintervention than does SAV. Our results demonstrate that SAV is safe and effective and that residual gradients and degree of AI are low. After SAV, the need for AVR can usually be delayed until the child is significantly older. The long-term functional stability after SAV is excellent. BAD in comparison is associated with an increased frequency and severity of AI and the need for earlier reintervention and valve replacement. SAV should be offered to all patients beyond the newborn period because it gives superior and longer lasting palliation.
对于选择双心室修复的先天性主动脉瓣狭窄（AS）患儿，可通过外科主动脉瓣成形术（SAV）或经导管球囊主动脉扩张术（BAD）实现瓣膜成形。本回顾性研究旨在比较 BAD 与 SAV 的疗效，评估长期生存率、主动脉瓣再狭窄或主动脉瓣关闭不全（AI）或两者的发生率，以及因重复瓣膜修复或置换而再次手术的无复发率。本比较排除了年龄小于 2 个月的新生儿。
我们回顾了本机构最近 20 年间行 SAV（n=89）和 BAD（n=69）修复的患儿的结局。分析了临床和超声心动图随访结果。比较了两组患儿术后主动脉瓣跨瓣压差和瓣叶关闭不全的持续或复发情况，以及包括主动脉瓣置换（AVR）在内的瓣叶相关再干预情况。
两组患儿的平均年龄、体表面积、瓣叶解剖结构、性别和术前跨瓣压差无显著差异。本研究数据表明，BAD 组的压差减小、AI 发生率和再干预需求较差。两组患儿末次随访时的主动脉瓣压差相似，但 BAD 组更早出现明显压差。行 SAV 的患儿出院时的主动脉瓣压差显著更好。Kaplan-Meier 分析显示，SAV 和 BAD 组在 10 年时的比较结果如下：无再干预率分别为 72%和 53%（p=0.02），无 AVR 率分别为 80%和 75%（p=0.32）。
与 SAV 相比，BAD 可导致较少的压差减小、更多的术后 AI 和初始及后续再干预之间的间隔更短。本研究结果表明，SAV 安全有效，残余压差和 AI 程度较低。SAV 后，AVR 的需求通常可延迟至患儿年龄较大时。SAV 后其长期功能稳定性极佳。相比之下，BAD 与 AI 发生率和严重程度增加以及更早的再干预和瓣膜置换需求相关。由于 SAV 可提供更好和更持久的姑息效果，应向所有新生儿期后的患儿提供 SAV。
