Surgical palliation or primary transplantation for aortic valve atresia

J Thorac Cardiovasc Surg. 2020 Apr;159(4):1451-1461.e7. doi: 10.1016/j.jtcvs.2019.08.104. Epub 2019 Sep 25.


Objective: The study objective was to describe the surgical pathway progression through adolescence of an inception cohort of neonates with aortic valve atresia managed initially with surgical palliation or primary transplantation, comparing survival and self-reported health-related quality of life.

Methods: From 1994 to 2000, 565 neonates with aortic atresia were admitted to 26 Congenital Heart Surgeons' Society hospitals and followed annually for vital status. Initial management included surgical palliation (n = 453) and primary cardiac transplantation (n = 68). PedsQL health-related quality of life questionnaires were sent cross-sectionally to a subgroup of 198 patients alive at previous follow-up, with 80 responses.

Results: Risk of death was initially high for both treatment strategies. However, compared with initial surgical palliation, survival with primary transplantation, including wait-list mortality, was greater and persisted long-term (65% vs 40% at 15 years; P = .002). Survival after secondary transplantation (48% at 9 years) was lower than after primary transplantation (74%). Health-related quality of life total score was lower overall than that of the general adolescent population (71 ± 16 vs 84 ± 13; P = .0001; normal = 100), but similar to that of adolescents with chronic diseases. It was similar in the surgical palliation and primary transplantation groups (70 ± 16 vs 75 ± 15; P = .3). Patients who received surgical palliation reported more symptoms (76 ± 15 vs 63 ± 18; P = .02).

Conclusions: Patients receiving primary heart transplantation for aortic atresia in 1994 to 2000 experienced better survival, fewer symptoms, and equivalent quality of life compared with those undergoing initial surgical palliation. Notwithstanding the limited availability of neonatal and infant donor hearts, primary transplantation may be considered for those neonates with risk factors predictive of exceptionally poor survival after surgical palliation.

Keywords: Fontan; aortic atresia; neonatal; quality of life; surgical palliation; survival; transplantation.

MeSH terms

  • Adolescent
  • Aortic Valve*
  • Child
  • Child, Preschool
  • Cohort Studies
  • Female
  • Heart Transplantation*
  • Heart Valve Diseases / mortality
  • Heart Valve Diseases / surgery*
  • Heart Valve Prosthesis Implantation
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Norwood Procedures
  • Palliative Care*
  • Quality of Life
  • Survival Rate
  • Treatment Outcome