Invited Commentary

Abstract

Alghamdi and associates [1Alghamdi A.A. Yanagawa B. Singh S.K. Horton A. Al-Radi O.O. Caldarone C.A. Balancing stenosis and regurgitation during mitral valve surgery in pediatric patients.Ann Thorac Surg. 2011; 92: 680-684Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] have highlighted the delicate balance that can be achieved between mitral stenosis and mitral regurgitation when repairing the mitral valve in children in order to achieve a more durable outcome and avoid mitral valve replacement. They show that greater than mild to moderate mitral regurgitation is poorly tolerated and an independent predictor of reoperation or death. The reduction of mitral regurgitation to less than moderate to mild by the creation of mild mitral stenosis makes for a better long-term repair. This approach of avoiding mitral valve replacement at the expense of a less-than-perfect repair, but one that is well tolerated with balanced regurgitation and stenosis, does allow for growth of the patient and removes the risks of anticoagulation with mitral valve replacement. Deferring mitral valve replacement to the older and larger patient allows a bigger valve to be placed. This article deals with patients of a median age of 4 years, with dysplastic valve morphology rather than the complex morphology seen in infancy, such as parachute mitral valve and where multiple obstructive lesions are present on the left side of the heart (Shone syndrome). Patients in the first few months and year of life are almost certainly more challenging than the cohort in article by Alghamdi and colleagues. However, the approach of achieving balanced mitral stenosis and mitral regurgitation, and a repaired valve, is certainly applicable to this younger, more difficult group. Long-term evaluation outcome for these patients should include the ability of the patient to thrive and develop and the lack of development of pulmonary hypertension. The mitral valve hemodynamics were assessed on the operating table under anaesthetic and probably underestimates the degree and severity of mitral stenosis and regurgitation. However, because this assessment mode was uniformly applied to all patients, it would seem to be acceptable. Mitral valve repair in young patients, particularly in the first few months of life, is difficult and challenging. The underlying morphology is complex, and individual variation in morphology from patient to patient makes each case a separate challenge. Although this report is in older children, the concept that a balanced repair that leaves mild to moderate valve regurgitation together with mild mitral stenosis to compensate for what otherwise would be severe mitral regurgitation, with a very bad outcome, seems eminently sensible. Balancing Stenosis and Regurgitation During Mitral Valve Surgery in Pediatric PatientsThe Annals of Thoracic SurgeryVol. 92Issue 2PreviewThe objectives of this study were to evaluate the composite outcome of reoperation or death for mitral valve repair and replacement and to determine the relative importance of regurgitation and stenosis during mitral valve repair to guide intraoperative decision making. Full-Text PDF