title: Aortic valve repair for insufficiency in older children offers unpredictable durability that may not be advantageous over a primary Ross operation†.
abstract: OBJECTIVE
  To evaluate the durability of aortic valve (AoV) repair relative to other strategies for children with significant aortic insufficiency (AI).
  
  
  METHODS
  From 2001 to 2012, 90 children with greater than or equal to moderate AI underwent surgery. Resulting procedures were classified according to final operative outcome: AoV repair (repair; n = 46, 51%), Ross procedure (Ross; n = 21, 23%) or replacement with mechanical or tissue prosthesis [aortic valve replacement (AVR); n = 23, 26%]. Repeated measures (n = 1081 echocardiograms) mixed-model analysis and parametric multiphase risk-adjusted hazard analysis were used to evaluate haemodynamic parameters and durability of operations.
  
  
  RESULTS
  Mean age at operation was similar for repair and Ross groups, but slightly higher for the AVR group (10.6, 11 and 13.2, respectively; P = 0.04). Baseline annular dimensions were similar among groups. Of 46 repairs, 85% involved pericardial leaflet extensions (commonly with leaflet shaving and/or commisuroplasty). The remaining repairs were commissuroplasties. On multivariable analysis, repair was associated with increased early (∼1-2 years) AI and increased outflow tract peak pressure gradients relative to Ross and AVR procedures. On univariate analysis, repairs tended to have a larger annulus size compared with Ross or AVR; however, this was not significant on multivariable analysis. There were 25 reinterventions (surgical reoperation = 16; transcatheter intervention = 9) for 22 children. Freedom from surgical reoperation was 64, 100 and 51% at 6 years for repairs, Ross and AVR, respectively (P = 0.05); however, three of five reoperations after AVR were for failed bioprosthetic devices. The freedom from reintervention was not significantly influenced by the type of AoV operation (P = 0.43).
  
  
  CONCLUSIONS
  Durability of aortic valve repair for children is limited by recurrence of AI and/or stenosis, often within the first few years. After repair, reoperation should be anticipated within ∼7 years.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada.
authors.forename: Travis J
authors.initials: TJ
authors.lastname: Wilder
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Caldarone
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada.
authors.forename: Glen S
authors.initials: GS
authors.lastname: Van Arsdell
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada.
authors.forename: Eric
authors.initials: E
authors.lastname: Pham-Hung
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Gritti
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada Prince Sultan Cardiac Center, Al-Ahsa, Saudi Arabia.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Al Jughiman
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada edward.hickey@sickkids.ca.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Hickey
mesh_terms: D000293:Adolescent; D000704:Analysis of Variance; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000453:epidemiology / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007223:Infant; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies
keywords: Aortic insufficiency; Aortic valve repair; Aortic valve replacement; Ross procedure