Aortic valve neocuspidization in children: A systematic review and meta-analysis

<h2>Abstract</h2><h3>Background</h3> Aortic valve neocuspidization (AVNeo) has emerged as a reconstructive alternative for children with aortic valve disease who are poor candidates for prosthetic replacement or the Ross procedure. Although early clinical results appear favorable, concerns persist regarding mid-term durability and material-related valve degeneration. To clarify these uncertainties, we systematically evaluated global pediatric AVNeo outcomes, focusing on early performance, mid-term reintervention rates, and the influence of pericardial material on valve longevity. <h3>Methods</h3> A systematic search of PubMed, Embase, Scopus, the Cochrane Library, and preprint servers (January 2000-October 2025) identified studies reporting neocuspidization in patients age ≤18 years. Two reviewers independently screened and extracted data. Pooled proportions were calculated with a random-effects model; heterogeneity was assessed with the <i>I</i>² statistic. Risk ratios compared reoperation rates between autologous and xenopericardial reconstructions, and comparative cohorts versus the Ross operation were summarized narratively. <h3>Results</h3> Twelve studies including 336 children met the inclusion criteria. Early mortality was 1.2%, and late mortality was 1.1%. The pooled reoperation rate was 15.4% (95% confidence interval [CI], 5.4%-29.2%; <i>I</i>² = 86%). Reoperation was 7-fold more frequent after xenopericardial reconstruction (risk ratio, 7.09; 95% CI, 2.95-17.06). Comparative series consistently favored the Ross operation for mid-term durability. <h3>Conclusions</h3> AVNeo provides excellent early outcomes but limited mid-term durability, particularly with xenopericardium. Autologous pericardium markedly reduces reoperation risk and should remain the preferred material.