Murphy Michael O, Beller Jared P, Bloom Jordan P, Montanaro Claudia, Hoschtitzky Andreas, Shore Darryl, Bautista Carles, Fraisse Alain
Department of Paediatric Cardiac Surgery, Royal Brompton Hospital & National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Adult Congenital Heart Disease, Royal Brompton Hospital & National Heart and Lung Institute, Imperial College London, London, United Kingdom.
Department of Paediatric Cardiac Surgery, Royal Brompton Hospital & National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Adult Congenital Heart Disease, Royal Brompton Hospital & National Heart and Lung Institute, Imperial College London, London, United Kingdom.
J Thorac Cardiovasc Surg. 2025 Apr;169(4):1033-1041.e1. doi: 10.1016/j.jtcvs.2024.09.043. Epub 2024 Oct 2.
To evaluate the influence of initial intervention on the long-term outcomes in congenital aortic stenosis.
Two hundred forty-three children underwent initial intervention between 1997 and 2022, by surgical valvuloplasty in 92 (32% neonates, 36% infants) and balloon valvuloplasty in 151 (27% neonates, 30% infants). Twenty-eight patients (11.5%) had associated mitral valve stenosis. Competing risk analysis for death, alive after initial intervention, or alive after aortic valve replacement (AVR) was performed and factors influencing survival or AVR examined.
There were 9 early deaths (3.7%). During a median follow-up of 13.5 years (range, 1.5-26.7), 98 patients had reintervention on the aortic valve (40.3%), whereas 145 had AVR (59.6%) at a median age of 14.0 years (interquartile range, 9.0-17.0), which was by Ross procedure in 130 (89.6%). Of the 12 late deaths, 3 were perioperative and 9 occurred as outpatients. There were no perioperative or late deaths after AVR. AVR occurred earlier in patients who had initial balloon (12.0 years [interquartile range, 5.0-14.5]) rather than surgical (18.5 years [interquartile range, 15.5-21.5]) valvuloplasty (P < .05). Actuarial survival in the cohort was 91.3% at 25 years, with no difference between the 2 initial interventions. Critical aortic stenosis, mitral stenosis, and initial intervention as a neonate were independent risk factors for worse survival.
We demonstrate excellent early and late survival in patients with congenital aortic stenosis after initial balloon or surgical valvuloplasty. Whilst children who had balloon valvuloplasty had AVR earlier than those who had initial surgical valvuloplasty, patient factors had a greater influence on survival than choice of initial intervention.
评估初始干预对先天性主动脉瓣狭窄长期预后的影响。
1997年至2022年间，243例儿童接受了初始干预，其中92例（32%为新生儿，36%为婴儿）接受了外科瓣膜成形术，151例（27%为新生儿，30%为婴儿）接受了球囊瓣膜成形术。28例患者（11.5%）合并二尖瓣狭窄。对死亡、初始干预后存活或主动脉瓣置换（AVR）后存活进行竞争风险分析，并检查影响生存或AVR的因素。
9例早期死亡（3.7%）。在中位随访13.5年（范围1.5 - 26.7年）期间，98例患者（40.3%）接受了主动脉瓣再次干预，而145例（59.6%）在中位年龄14.0岁（四分位间距9.0 - 17.0岁）时接受了AVR，其中130例（89.6%）采用Ross手术。12例晚期死亡中，3例为围手术期死亡，9例为门诊患者死亡。AVR后无围手术期或晚期死亡。接受初始球囊瓣膜成形术的患者比接受外科瓣膜成形术的患者更早接受AVR（分别为12.0岁[四分位间距5.0 - 约14.5岁]和18.5岁[四分位间距15.5 - 21.5岁]，P < 0.05）。该队列25年时的精算生存率为91.3%，两种初始干预方法之间无差异。重度主动脉瓣狭窄（临界型）、二尖瓣狭窄以及新生儿期进行初始干预是生存较差的独立危险因素。
我们证明了先天性主动脉瓣狭窄患者在接受初始球囊或外科瓣膜成形术后具有良好的早期和晚期生存率。虽然接受球囊瓣膜成形术的儿童比接受初始外科瓣膜成形术的儿童更早接受AVR，但患者因素对生存的影响大于初始干预方式的选择。
