Surgical management of aortic valve disease in an older child may include:

A. Enlargement of the aortic annulus.

B. Incision of fused commissures.

D. Transfer of the pulmonary valve to the aortic position.

DISCUSSION: The majority of older children with aortic stenosis and significant transvalvular gradients can be treated successfully by aortic valvotomy. This can be done percutaneously with balloon dilatation or surgically with direct visualization of the aortic valve and incision of the fused commissures. Aortic valve replacement is rarely necessary as a primary procedure but may be required in children who develop progressive aortic insufficiency after a previous intervention. When valve replacement is performed it is desirable to insert the largest prosthesis possible, to allow for growth. Enlargement of the aortic annulus is commonly performed for this purpose. If a true valve prosthesis is employed, a mechanical valve is preferred. Durability of xenograft valves in children is limited owing to early calcification and leaflet degeneration. The pulmonary autograft technique may be the best method of aortic valve replacement in children. With this operation the patient's own pulmonary valve is transferred to the aortic position and a pulmonary allograft is inserted to replace the pulmonary valve. Although the pulmonary autograft may not achieve the long-term durability of a mechanical valve, the patient does not face the long-term complications of thromboembolism and bleeding imposed by a mechanical valve and lifelong anticoagulation.