Surgical valvotomy for congenital aortic stenosis was the treatment for childhood aortic stenosis for over 30 years before balloon aortic valvoplasty. Unfortunately there are no trials of appropriate design to allow a valid comparison of surgery and balloon valvotomy. When considering the best treatment for childhood aortic stenosis by necessity we must rely on data which is fraught with problems. Existing studies are retrospective and non-randomised, reporting different age groups using varied techniques across a number of eras. A major problem in the literature is the significant variation in indication for intervention and reintervention.

Even allowing for such inconsistencies both techniques seem broadly comparable in terms of immediate gradient relief, procedural mortality, and longer term survival.^4–12 There are relatively recent reports of encouraging survival rates with both surgery and balloon valvotomy even in the troublesome neonatal group in which triage for a Norwood approach based on an improved understanding of the limits of a biventricular repair must have played a significant part.^12–14

Valvotomy of any kind is a palliative procedure and reintervention remains frequent. As longer term data emerges reintervention rates after balloon valvotomy become of some concern. Reich and colleagues report overall intervention-free survival of 39% to 14.4 years.¹ In the neonatal group the results are worse with 29% of patients in this study surviving to 14.4 years without reintervention and just 35% surviving without a second procedure to three years in the study by Balmer and colleagues.^1,2 A mixture of recurrent aortic stenosis and important regurgitation were the indications for further procedures. These data are not out of context with the existing balloon valvoplasty literature in which other authors report 50% of children requiring reintervention by eight years after the initial valvotomy.⁶

Studies that report non-randomised comparisons of balloon and surgical valvotomy generally report similar results (including reintervention rates) for both approaches, but important demographic differences between groups are always present.^4,12,17

It may be that given the high reintervention rate in this group there is an even stronger argument for balloon valvotomy as initial palliation, so avoiding a sternotomy in a patient in whom reintervention is almost certain.

Reich and Balmer are to be commended on their echocardiographic follow up.^1,2 Using consistent criteria both sets of authors report what others have previously suggested after both forms of aortic valvotomy—that is, that aortic regurgitation is progressive. We should not be surprised by this; normal aortic valves leak progressively with age and it is possible that in anatomically abnormal valves, the process is accelerated.^24,25 Unrecognised cusp avulsion and perforation after balloon valvotomy is relatively common^20,26 and perhaps this further increases the rate of the degenerative process in the balloon group leading to earlier reintervention.

However, of serious concern after balloon aortic valvoplasty is the high incidence of procedural femoral artery damage which is a consistent feature in reported series, particularly in infants.^6,14 Balmer and colleagues report femoral artery occlusion requiring treatment in 57% of infants less than 3 months of age.² Magnetic resonance imaging studies of iliofemoral vessels after balloon angioplasty show that the majority of children have evidence of obstructive lesions.²⁸ Other procedural approaches are reported in small numbers, but as yet we have little or no evidence of the long term implications for these vessels.²⁹

Both balloon and surgical valvotomy are firmly established as effective initial treatments in childhood aortic stenosis; as such, it is exceedingly unlikely that we will ever have robust randomised data to really say what the best treatment is for the child with aortic stenosis. We cannot conclude with any certainty that reintervention comes any earlier after balloon valvotomy, but it seems clear that aortic regurgitation is progressive and reintervention almost inevitable. As in many aspects of the management of the patient with congenital heart disease difficult anatomy is a challenge for everyone concerned with treatment. Further consideration to the approach for balloon angioplasty, particularly in infants and neonates given the high incidence of long term femoral artery damage, seems appropriate.