OP-ICVA210118 1..9

OBJECTIVES: Surgical repair of subaortic stenosis (SAS) is associated with a substantial reoperation risk. We aimed to identify risk factors for reintervention in relation to discrete and tunnel-type SAS morphology. METHODS: Single-centre retrospective study of paediatric SAS diagnosed between 1992 and 2017. Multivariable Cox regression analysis was performed to identify reintervention risk factors. RESULTS: Eighty-five children [median age 2.5 (0.7–6.5) years at diagnosis] with a median follow-up of 10.1 (5.5–16.4) years were included. Surgery was executed in 83% (n = 71). Freedom from reoperation was 88 ± 5% at 5 years and 82 ± 6% at 10 years for discrete SAS, compared to, respectively, 33 ± 16% and 17 ± 14% for tunnel-type SAS (log-rank P < 0.001). Independent risk factors for C O N G EN IT A L VC The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Interactive Cardiovascular and Thoracic Surgery (2021) 1–9 ORIGINAL ARTICLE doi:10.1093/icvts/ivab121 D ow naded rom http/academ ic.p.com /icvts/advance-art.1093/icvts/ivab121/6277152 by gest on 19 M ay 2021 reintervention were a postoperative gradient >20 mmHg [hazard ratio (HR) 6.56, 95% confidence interval (CI) 1.41–24.1; P = 0.005], tunnel-type SAS (HR 7.46, 95% CI 2.48–22.49; P < 0.001), aortic annulus z-score <-2 (HR 11.07, 95% CI 3.03–40.47; P < 0.001) and age at intervention <2 years (HR 3.24, 95% CI 1.09–9.86; P = 0.035). Addition of septal myectomy at initial intervention was not associated with lesser reintervention. Fourteen children with a lower left ventricular outflow tract (LVOT) gradient (P < 0.001) and older age at diagnosis (P = 0.024) were followed expectatively. CONCLUSIONS: Children with SAS remain at risk for reintervention, despite initially effective LVOT relief. Regardless of SAS morphology, age <2 years at first intervention, a postoperative gradient >20 mmHg and presence of a hypoplastic aortic annulus are independent risk factors for reintervention. More extensive LVOT surgery might be considered at an earlier stage in these children. SAS presenting in older children with a low LVOT gradient at diagnosis shows little progression, justifying an expectative approach.

[1]  D. De Wolf,et al.  The pulmonary autograft after the Ross operation: Results of 25 year follow-up in a pediatric cohort. , 2020, The Annals of thoracic surgery.

[2]  L. Abushaban,et al.  Long-term follow-up and outcomes of discrete subaortic stenosis resection in children , 2019, Annals of pediatric cardiology.

[3]  R. Ohye,et al.  Routine Septal Myectomy During Subaortic Stenosis Membrane Resection: Effect on Recurrence Rates , 2018, Pediatric Cardiology.

[4]  E. Bacha,et al.  When Is It Better to Wait? Surgical Timing and Recurrence Risk for Children Undergoing Repair of Subaortic Stenosis , 2017, Pediatric Cardiology.

[5]  P. D. del Nido,et al.  Long-term outcomes and risk factors for aortic regurgitation after discrete subvalvular aortic stenosis resection in children , 2015, Heart.

[6]  D. Rizopoulos,et al.  Natural history of discrete subaortic stenosisin adults: a multicentre study. , 2013, European heart journal.

[7]  D. Rizopoulos,et al.  Surgical Outcome of Discrete Subaortic Stenosis in Adults: A Multicenter Study , 2013, Circulation.

[8]  Alexandra Gonçalves,et al.  The natural history of congenital subaortic stenosis. , 2011, Congenital heart disease.

[9]  D. Schranz,et al.  The dilemma of subaortic stenosis--a single center experience of 15 years with a review of the literature. , 2011, The Thoracic and cardiovascular surgeon.

[10]  C. Rohlicek,et al.  Long-term pediatric outcome of isolated discrete subaortic stenosis. , 2011, The Canadian journal of cardiology.

[11]  Jonathan M. Chen,et al.  The role of enucleation with or without septal myectomy for discrete subaortic stenosis. , 2009, The Journal of thoracic and cardiovascular surgery.

[12]  V. Rousson,et al.  Risk factors for reoperation after relief of congenital subaortic stenosis. , 2008, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[13]  P. D. del Nido,et al.  Risk factors for reoperation after repair of discrete subaortic stenosis in children. , 2007, Journal of the American College of Cardiology.

[14]  W. Williams,et al.  Prevalence and associated risk factors for intervention in 313 children with subaortic stenosis. , 2007, The Annals of thoracic surgery.

[15]  J. Child,et al.  Left ventricular outflow obstruction: subaortic stenosis, bicuspid aortic valve, supravalvar aortic stenosis, and coarctation of the aorta. , 2006, Circulation.

[16]  A. Guzeltas,et al.  Echocardiographic Follow-Up of Children with Isolated Discrete Subaortic Stenosis , 2006, Pediatric Cardiology.

[17]  M. Turrentine,et al.  Long-term results of surgical repair in patients with congenital subaortic stenosis. , 2006, Interactive cardiovascular and thoracic surgery.

[18]  K. Gauvreau,et al.  Risk factors for aortic valve dysfunction in children with discrete subvalvar aortic stenosis. , 2004, The American journal of cardiology.

[19]  P. Gallego,et al.  Discrete subaortic stenosis in adults: increased prevalence and slow rate of progression of the obstruction and aortic regurgitation. , 2001, Journal of the American College of Cardiology.

[20]  C. Rohlicek,et al.  Natural history and surgical outcomes for isolated discrete subaortic stenosis in children , 1999, Heart.

[21]  N. Silverman,et al.  Resection of subaortic stenosis; can a more aggressive approach be justified? , 1999, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[22]  L. Galletti,et al.  Surgical treatment of subaortic stenosis: a seventeen-year experience. , 1999, The Journal of thoracic and cardiovascular surgery.

[23]  E. Fisher,et al.  Modified Konno-Rastan procedure for subaortic stenosis: indications, operative techniques, and results. , 1998, The Annals of thoracic surgery.

[24]  H. Laks,et al.  Benefits of early surgical repair in fixed subaortic stenosis. , 1997, Journal of the American College of Cardiology.

[25]  J. Y. Choi,et al.  Fixed subaortic stenosis: anatomical spectrum and nature of progression. , 1991, British heart journal.

[26]  R. Hurwitz,et al.  Surgery for discrete subvalvular aortic stenosis: actuarial survival, hemodynamic results, and acquired aortic regurgitation. , 1985, The Annals of thoracic surgery.

[27]  D. Ross,et al.  Technique for the relief of discrete subaortic stenosis. , 1982, The Journal of thoracic and cardiovascular surgery.

[28]  M H Paul,et al.  Discrete subvalvular aortic stenosis in childhood. Study of 51 patients. , 1976, The American journal of cardiology.