Hawkins J A, Minich L L, Shaddy R E, Tani L Y, Orsmond G S, Sturtevant J E, McGough E C
Department of Surgery, University of Utah, Salt Lake City, USA.
Ann Thorac Surg. 1996 May;61(5):1355-8. doi: 10.1016/0003-4975(96)00018-5.
Little is known about the incidence, indications, and results of surgical repair or replacement of the aortic valve after balloon aortic valvuloplasty (BAV) for congenital aortic stenosis in children. This study was designed to evaluate patterns of failure requiring operation after BAV for congenital aortic stenosis and to review our experience with successful repair, rather than replacement, of selected aortic valves after BAV.
From March 1986 to June 1995, 60 patients with congenital aortic stenosis aged 1 day to 27 years (mean +/- standard deviation, 7.3 +/- 6 years) underwent BAV. Twenty-three patients (38%) required operation a mean of 44 +/- 37 months (range, 1 to 110 months) after BAV, because of severe aortic insufficiency in 13 patients and recurrent or residual aortic stenosis in 10 patients. Severe aortic insufficiency was invariably due to avulsion of a cusp from the annulus, with resulting cusp prolapse and insufficiency. Operative intervention consisted of valve replacement in 14 patients and valve repair in 9 patients. Repair techniques included reattachment of an avulsed cusp to the aortic annulus, relief of commissural fusion, and debridement of thickened cusps.
Actuarial freedom from surgical intervention after BAV was 88% +/- 4% at 1 year, 70% +/- 6% at 5 years, and 51% +/- 12% at 9 years. The need for aortic valve operation was unrelated to age at the time of BAV, indication for operation (aortic insufficiency versus aortic stenosis), age of operation, or preoperative gradient. All patients survived aortic valve operation; there was one late death at an average follow-up of 27 +/- 20 months (range, 2 to 61 months) after aortic valve operation. Stenosis was well relieved in all patients undergoing valve replacement. The 9 valve repair patients have been followed for 22 +/- 14 months (range, 1 to 47 months). Echocardiographic follow-up of the valve repair patients revealed a mean residual aortic stenosis peak instantaneous gradient of 32 mm Hg and mild aortic insufficiency or less in all patients.
Aortic valve operation is required in 5% to 7% of patients yearly after BAV. The need for operation appears to be unrelated to age at the time of BAV; aortic insufficiency predominates over aortic stenosis as an indication for operative intervention. Valve repair can be applied in some patients after BAV with good intermediate-term results and may delay the need for aortic valve replacement.
对于儿童先天性主动脉瓣狭窄行球囊主动脉瓣成形术（BAV）后主动脉瓣手术修复或置换的发生率、适应证及结果了解甚少。本研究旨在评估先天性主动脉瓣狭窄行BAV后需要手术的失败模式，并回顾我们对BAV后部分主动脉瓣成功修复而非置换的经验。
1986年3月至1995年6月，60例年龄1天至27岁（平均±标准差，7.3±6岁）的先天性主动脉瓣狭窄患者接受了BAV。23例患者（38%）在BAV后平均44±37个月（范围1至110个月）需要手术，其中13例因严重主动脉瓣关闭不全，10例因复发性或残余性主动脉瓣狭窄。严重主动脉瓣关闭不全均因瓣叶从瓣环撕脱，导致瓣叶脱垂和关闭不全。手术干预包括14例瓣膜置换和9例瓣膜修复。修复技术包括将撕脱的瓣叶重新附着于主动脉瓣环、解除瓣叶融合以及清除增厚的瓣叶。
BAV后1年、5年和9年无需手术干预的精算生存率分别为88%±4%、70%±6%和51%±12%。主动脉瓣手术的需求与BAV时的年龄、手术适应证（主动脉瓣关闭不全与主动脉瓣狭窄）、手术年龄或术前压差无关。所有患者均存活主动脉瓣手术；主动脉瓣手术后平均随访27±20个月（范围2至61个月）时有1例晚期死亡。所有接受瓣膜置换的患者狭窄均得到良好缓解。9例瓣膜修复患者已随访22±14个月（范围1至47个月）。瓣膜修复患者的超声心动图随访显示，所有患者平均残余主动脉瓣狭窄峰值瞬时压差为32 mmHg，且主动脉瓣关闭不全为轻度或更轻。
BAV后每年有5%至7%的患者需要行主动脉瓣手术。手术需求似乎与BAV时的年龄无关；作为手术干预的适应证，主动脉瓣关闭不全比主动脉瓣狭窄更为常见。瓣膜修复可应用于部分BAV后的患者，中期效果良好，且可能延迟主动脉瓣置换的需求。
