Congenital aortic stenosis is a condition with implications of multiple interventions over a lifetime. We therefore read with interest the report by Maskatia et al reporting their 25-year single-institutional experience of primary intervention with balloon valvuloplasty. Clearly, balloon angioplasty has come of age. The information regarding survival and reintervention was very useful. What was surprising about this report was that there was no mention of the primary surgical approach for valvar aortic stenosis. The primary surgical approach was also not mentioned in a very impressive, large single-institutional series reported by Brown et al, which did mention the role of surgery for aortic valve replacement for balloon valvuloplasty sequelae. Even more surprising was that surgery was not mentioned at all in the editorial comment on the report by Brown et al. Another recent report on the long-term experience of balloon valvuloplasty from a large single institution by Fratz et al concluded that balloon valvuloplasty successfully postponed surgery. There was also no reference to primary surgical treatment of valvar aortic stenosis. Although recent reports of the results of surgical aortic valvuloplasty are lacking for obvious reasons, a not too exhaustive review of the published research found earlier reports by Brown et al, Elkins et al, and Detter et al, which all reported outcomes in terms of acute and long-term survival and reintervention rates in large numbers of patients from single institutions. The follow-up periods were quite long, implying that the initial diagnosis, surgery, and postoperative care were performed at a time when these were much less developed than they are today.

Although it does not require statistical methods to conclude that balloon valvuloplasty is a much less invasive procedure than open-heart surgery, there does seem to be a reluctance to perform a comparison of the long-term success of the 2 procedures similar to the one by McCrindle et al comparing 5-year outcomes for critical neonatal aortic stenosis. Their study found similar 5-year outcomes for primary balloon and surgical valvuloplasty. The earlier surgical and these balloon valvuloplasty reports used similar methods to present their acute mortality, gradient reduction, and their >20-year long-term follow-up results with Kaplan-Meier graphs, censoring for death, reintervention, and, in some cases, aortic regurgitation. For physicians involved with caring for children with this condition, it must be asked if it is reasonable to have to interpret each center’s results in isolation. Because balloon valvuloplasty is the more recent intervention, should a comparison, or at least a discussion of the results of the 2 procedures as primary interventions, be a requirement for publication? In the absence of randomized trials, and given that the results that must be compared are not contemporaneous, this may be a difficult task but not an insurmountable one, as shown by McCrindle et al.

This comparative information would assure noninterventional pediatric cardiologists and, more important, patients’ families that the long-term outcomes of balloon valvuloplasty are superior, or at least equivalent, to those of surgery. If they are not, there are implications for informed consent and, given that multiple interventions over a lifetime are anticipated, the decision needs to be made whether short-term pain is worth long-term gain.