Melody Valve for Mitral Valve Replacement

Abstract

In certain pediatric patients with irreparable mitral valve disease, mitral valve replacement is necessary. One option for replacement in a child with small annulus is off label use of the Melody valve for mitral replacement. The device modifications and implantation technique are described, and focus on maneuvers to prevent perivalvular leak and left ventricular outflow tract obstruction. Short term results are acceptable, but long term performance of this valve in this position is still unknown. In certain pediatric patients with irreparable mitral valve disease, mitral valve replacement is necessary. One option for replacement in a child with small annulus is off label use of the Melody valve for mitral replacement. The device modifications and implantation technique are described, and focus on maneuvers to prevent perivalvular leak and left ventricular outflow tract obstruction. Short term results are acceptable, but long term performance of this valve in this position is still unknown. Options for mitral valve replacement in children with irreparable mitral valve are limited, particularly for annular size less than 15 mm. Recent experience with a bovine jugular vein graft (Melody® valve) for mitral replacement has demonstrated acceptable short-term results. Advantages of this valve include favorable effective orifice area index and potential for subsequent expansion by percutaneous catheter-based balloon dilation as the child grows. Certain design features of the device make it favorable for implantation into the right ventricular outflow tract yet make it less favorable for implantation into the mitral position. The length of the device (2.3-2.5 cm) predisposes it to protrusion into the left ventricle (LV), leading to left ventricular outflow tract obstruction (LVOTO). The device lacks a sewing cuff to anchor the device to the mitral annulus. Modification of the device and specific implantation techniques are described to allow implantation and avoid LVOTO. The Melody valve appears to function well at short-term follow-up, with complications including LVOTO in 10% of patients.1Abdullah I. Ramirez F.B. McElhinney D.B. et al.Modification of a stented bovine jugular vein conduit (melody valve) for surgical mitral valve replacement.Ann Thorac Surg. 2012; 94: e97-e98Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 2Hofmann M. Dave H. Hubler M. et al.Simplified surgical-hybrid Melody® valve implantation for paediatric mitral valve disease.Eur J Cardiothorac Surg. 2014; ([epub ahead of print])Google Scholar Balloon expansion of the valve at up to 4 years following implantation has been successful at preserving valvular competence and low gradient. Reoperation for perivalvular leak and LVOTO remains a concern and requires close follow-up. Perivalvular leaks and LVOTO can be managed with transcatheter techniques, whereas severe LVOTO may require reoperation.3Quinonez L.G. Breitbart R. Tworetsky W. et al.Stented bovine jugular vein graft (Melody valve) for surgical mitral valve replacement in infants and children.J Thorac Cardiovasc Surg. 2014; 148: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Future development of a devices that is specifically designed for implantation into the mitral position with sewing cuff and shorter profile may reduce the incidence of perivalvular leaks and LVOTO.