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Original research
Multicentre comparative analysis of long-term outcomes after aortic valve replacement in children
  1. Jessica H Knight1,
  2. Amber Leila Sarvestani2,
  3. Chizitam Ibezim2,
  4. Elizabeth Turk2,
  5. Courtney E McCracken3,
  6. Bahaaldin Alsoufi4,
  7. James St Louis5,
  8. James H Moller6,
  9. Geetha Raghuveer2,
  10. Lazaros K Kochilas3,7
  1. 1 Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
  2. 2 Department of Pediatrics, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri, USA
  3. 3 Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
  4. 4 Department of Surgery, University of Louisville, Louisville, Kentucky, USA
  5. 5 Department of Surgery, Augusta University Medical College of Georgia, Augusta, Georgia, USA
  6. 6 School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
  7. 7 Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
  1. Correspondence to Dr Jessica H Knight, Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA; jessica.knight{at}


Objective The ideal valve substitute for surgical intervention of congenital aortic valve disease in children remains unclear. Data on outcomes beyond 10–15 years after valve replacement are limited but important for evaluating substitute longevity. We aimed to describe up to 25-year death/cardiac transplant by type of valve substitute and assess the potential impact of treatment centre. Our hypothesis was that patients with pulmonic valve autograft would have better survival than mechanical prosthetic.

Methods This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, a multi-institutional US-based registry of paediatric cardiac interventions, linked with the National Death Index and United Network for Organ Sharing through 2019. Children (0–20 years old) receiving aortic valve replacement (AVR) from 1982 to 2003 were identified. Kaplan-Meier transplant-free survival was calculated, and Cox proportional hazard models estimated hazard ratios for mechanical AVR (M-AVR) versus pulmonic valve autograft.

Results Among 911 children, the median age at AVR was 13.4 years (IQR=8.4–16.5) and 73% were male. There were 10 cardiac transplants and 153 deaths, 5 after transplant. The 25-year transplant-free survival post AVR was 87.1% for autograft vs 76.2% for M-AVR and 72.0% for tissue (bioprosthetic or homograft). After adjustment, M-AVR remained related to increased mortality/transplant versus autograft (HR=1.9, 95% CI=1.1 to 3.4). Surprisingly, survival for patients with M-AVR, but not autograft, was lower for those treated in centres with higher in-hospital mortality.

Conclusion Pulmonic valve autograft provides the best long-term outcomes for children with aortic valve disease, but AVR results may depend on a centre’s experience or patient selection.

  • congenital abnormalities
  • heart valve prosthesis

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors JHM and then LKK have been directors of the PCCC dataset. JK, ALS, CI, LKK, GR and ET led conceptualisation and data collection effort for this analysis. JK and CEM conducted the statistical analysis. JK, LKK, BA, JSL, JHM and GR were involved in the interpretation of the results. JK and ALS led the writing effort, but all coauthors also contributed to this and have reviewed all aspects of the manuscript.

  • Funding This study was supported by National Heart, Lung, and Blood Institute R01 HL122392 and the Department of Defence PR180683.

  • Disclaimer The data reported here have been supplied by UNOS as the contractor for the Scientific Organ Procurement and Transplantation Network (OPTN). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the OPTN or the US Government.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.