The debate between the best therapeutic approach to congenital aortic stenosis is
ongoing. Multiple studies have attempted to answer this question without reaching
a definitive conclusion. McCrindle et al performed the landmark analysis of the congenital
heart surgeon database and they showed equivalent results in the outcome between surgical
aortic valvotomy (SAV) versus balloon aortic valvuloplasty (BAV). Given similar outcomes,
many centers preferentially perform BAV due to its minimally invasive nature and faster
recovery. Some more recent single-center studies have shown better outcomes with surgical
valvotomy; however, their results were attributed to the use of contemporary superior
surgical techniques. In this study, we perform a contemporary systematic review and
meta-analysis to compare the effects of BAV and SAV on patient morbidity and mortality.
METHODS AND RESULTS
We searched MEDLINE and EMBASE from inception to March 2021 for studies comparing
balloon aortic valvuloplasty versus surgical commissurotomy for critical congenital
AS in patients younger than 18. We performed title and abstract screening, full-text
assessment, risk of bias assessment using the CLARITY tool, and data collection independently
and in duplicate. We pooled data using the random-effects model and Mantel-Haensel
statistical method. We evaluated the overall quality of evidence using the GRADE framework.
From a total of 439 studies imported for screening, 12 studies (1214 participants)
were included that compared outcomes for balloon aortic valvuloplasty and surgical
commissurotomy in the pediatric population. Mortality at 30-day and at longest follow-up
was not statistically significant between the two groups (RR 0.66 95% CI [0.34, 1.27]
and 0.74 95% CI [0.35, 1.56]. Reintervention favoured surgical repair at the longest
follow-up but did not reach statistical significance (RR 1.11 95% CI [0.89, 1.38]).
Postprocedural aortic insufficiency was more common after balloon valvotomy but failed
to reach statistical significance (RR: 1.5 95% CI 0.99 – 2.99).
In pediatric patients with congenital AS, surgical commissurotomy did not offer additional
advantages over balloon valvotomy. There was a trend toward an increase in post-procedural
AI and an increased rate of reintervention with balloon valvotomy. However, the quality
of evidence is very low. An appropriately powered large study is required to adequately
address the risks and benefits of the two interventions.