Surgical spectrum of aortic stenosis in children: a thirty-year experience with 257 children.

Aortic stenosis accounts for 5 to 6% of infants and children seen for surgical repair of congenital heart disease. The clinical presentation and reported results of operation for aortic stenosis are highly variable. This retrospective review was undertaken to assess our operative mortality and the degree of gradient reduction afforded by each of several surgical techniques used to treat aortic stenosis in children over a 30-year period. Two hundred fifty-seven patients ranging in age from 1 day to 19 years were operated on between 1957 and 1986. The indication for operation included asymptomatic patients with gradients greater than 50 mm Hg to patients in profound cardiogenic shock. The operative mortality for children older than 6 months was 4%, whereas neonates seen with critical aortic stenosis had a 60% mortality. The late mortality was 2%. Eighty percent of surviving patients to date have undergone cardiac catheterization after repair. This shows an overall reduction of 57 mm Hg in the left ventricular-aortic gradient. Patients with supravalvular aortic stenosis and discrete subvalvular aortic stenosis as well as patients undergoing aortic valve replacement showed a reduction in or elimination of associated aortic insufficiency, whereas patients undergoing aortic valvotomy or neonates having valvotomy had a significant increase in demonstrable aortic insufficiency. The incidence of third-degree heart block or cerebral emboli following operation for aortic stenosis was less than 1%. However, the incidence of late bacterial endocarditis following repair was nearly 5%; six of eleven cases occurred in the group with discrete subvalvular aortic stenosis. Twenty-nine (13%) of the 223 long-term survivors have undergone a subsequent procedure for relief of residual or recurrent obstruction; 12 have had insertion of an aortic valve prosthesis, 12 have had insertion of an apicoaortic conduit, and 6 have required repeat aortic valvotomy. These data demonstrate the low operative mortality and excellent hemodynamic benefit of surgical relief of single-level aortic stenosis in children older than neonates. Conduits placed for complex obstructions or operative procedures in neonates have acceptable hemodynamic benefits, but operative mortality remains high.