Introduction: Aortic valve replacement (AVR) in paediatric populations is associated to significant considerations. These include: the valve having to grow alongside the patient; the valve degrading over time, and a mechanical valve prosthesis requiring long-term anticoagulation. All of these have significant risks, contributing to decrease in survival time and need for reoperations. Due to this, aortic valve repair can be seen as an option to mitigate these drawbacks, preserving the native valve.However, repair is not always feasible, in such cases replacement will need to be considered. There are now several options available to replace a native aortic valve. Traditionally it is noted that paediatric AVR is associated with substantial mortality rates, with the Ross procedure preferred due to a survival benefit.Aims: Often, the choice of procedure is due to surgical preference. Transcatheter Aortic Valve Insertion, which has been well established for several years in adults has now started to be implemented into paediatric populations.The main aim of this study is to compare the early and late mortality, and infective endocarditis risk between different types of studies, to aid clinicians with decision making.Methods and Results: The initial phase of the study required a systematic review of published literature reporting mortality following paediatric AVR (maximum age <21), published between 1/1/1990 and 1/1/2025. Publications reporting outcomes after paediatric Ross, bioprosthetic AVR, homograft AVR, mechanical AVR, and TAVI were included. Due to similarities in surgical technique, bioprosthetic, homograft and mechanical AVR were classed as Surgical AVR. The early (<30 day) and long term (within follow-up) data for mortality was extracted. In total 13 retrospective cohort studies were included, from which there were 18 cohorts which were compared. Out of these 18 cohorts, eight were related to the Ross procedure, three to Surgical AVR and one to TAVI.The average age between the procedures varied as well, with the Ross procedure being used across age groups, with a range of 10.5 years compared to 8.1 of Surgical AVR, likely because of the propensity for the autograft and homograft to grow with the patient. The Ross procedure demonstrated an early mortality of 3.46% (CI 95%: 0.88% - 6.05%), compared to 13.42% (3.80% - 23.04%) for Surgical AVR and 0% for the single TAVI cohort. Comparatively, the Ross procedure also demonstrated a reduced follow-up mortality of 6.93% (2.39% - 11.48%), compared to 26.58% (10.80% - 42.37%) Surgical AVR. With the sole TAVI cohort demonstrating a similar follow-up mortality to that of the Ross procedure, of 6.25%.Conclusion: Paediatric AVR, regardless of procedure, is associated with a significant mortality risk; with the choice of procedure being associated with surgical preference alongside valve selection based on patient factors. Despite this, the Ross procedure demonstrated a sustained survival benefit. Alongside this, the emergence of TAVI procedures demonstrates a promising, less invasive alternative; however, this is demonstrated in a single cohort, and further research would need to be done to properly evaluate its long-term use.
