Initial Mitral Valve Replacement Research Articles

Patient–Prosthesis Mismatch Associated With Somatic Growth After Mechanical Mitral Valve Replacement in Small Children: Metrics for Reoperation and Outcomes

Reoperation after pediatric mitral valve replacement (MVR) is inevitable due to patient-prosthesis mismatch (PPM) associated with somatic growth. We analyzed potential metrics for PPM and outcomes of redo MVR for valve upsizing. Between 1999 and 2018, 15 children without obstructive left heart lesions other than mitral stenosis underwent initial MVR with a 16-mm ATS-Advanced Performance valve. We analyzed hemodynamic data from 28 postoperative catheterizations and concomitant echocardiograms. The median age and body weight at initial MVR were 4.9 months (25th, 75th percentile: 3.6, 6.6) and 5.9 kg (5.0, 7.3). Redo MVR was planned when patients had congestive heart failure and postcapillary pulmonary hypertension (PH) due to PPM: systolic pulmonary arterial pressure (SPAP) >35 mm Hg and pulmonary capillary wedge pressure (PCWP) >15 mm Hg on catheterization. Indexed effective orifice area (iEOA) and mean transmitral pressure gradient (TMPG) were strongly correlated with SPAP (r = -0.72, P < 0.001 and r = 0.75, P < 0.001) and PCWP (r = -082, P < 0.001 and r = 0.84, P < 0.001). Cut-off values for detecting postcapillary PH due to PPM were 1.0 cm2/m2 for iEOA and 18 mm Hg for mean TMPG. Nine patients underwent redo MVR for postcapillary PH due to PPM at a median postoperative interval of 10 years (9.2, 11.9). All the patients survived, and PH was improved one year after surgery. iEOA and mean TMPG can be metrics for PPM in children after MVR. Careful follow-up is required to confirm the improvement of preoperatively existing PH after redo MVR for valve upsizing.

Acute and Short-Term Outcomes of Percutaneous Transcatheter Mitral Valve Replacement in Children.

[Figure: see text].

Long-term outcomes of mitral valve replacement in patients weighing less than 10\u2009kg

BackgroundThe outcomes of mitral valve replacement (MVR) in pediatrics especially in the patients weighing less than 10 kg are not always favorable. This study aimed to measure long-term outcomes of MVR in our institution.MethodsNine young children weighing less than 10 kg underwent MVR with mechanical prostheses were enrolled in this retrospectively study. Kaplan–Meier survival analysis was used for the prediction of freedom from death and adverse events. Chi-square test was performed to compare outcomes for patients with different ratios of mechanical prosthesis size and body weight. Fourteen related literatures were also reviewed to support our study.ResultsAll patients received bileaflet mechanical prostheses replacement. The surgical technique varied among the patients with prostheses implanted in the intra-annular (n = 5), supra-annular (n = 1), or with a Dacron conduit segment in the supra-annular position (n = 3). The valve size/weight ratio ranged from 2.11 to 5.00. There were two early death and one late death post-operation. The mean follow-up period was 80.67 ± 63.37 months, the transvalvular gradient was 10.5 ± 1.76 mmHg (range 8 to 12) and the peak gradient of LVOT was 5.00 ± 0.64 mmHg. One (11.1%) patient underwent an immediate revision MVR after initial MVR due to the periprosthetic leak. No patients required surgical reintervention or permanent pacemaker placement during long-term follow-up.ConclusionsThe tailored surgical strategy utilized for MVR in infants resulted in reliable valve function and excellent survival. Although revision is inevitable due to somatic growth, the bileaflet mechanical prostheses displayed appropriate durability.

Abstract 17193: Acute and Short-Term Outcomes of Percutaneous Transcatheter Mitral Valve Replacement in Children

Introduction: Despite the improvement of surgical techniques for mitral valve (MV) repair in children, mitral valve replacement (MVR) is sometimes still necessary. MVR and redo-MVR continue to be burdened by early postoperative mortality and long-term morbidity with only about 75% of these patients being alive or transplant-free 10 years after the initial MVR. Although trans-femoral mitral valve replacement (TMVR) is a well-established intervention in high surgical risk adults, only a few pediatric Valve-in-Valve (ViV) case reports have been published. Hypothesis: We hypothesized that trans-venous transcatheter mitral valve replacement is feasible, safe, and effective in pediatric patients. Methods: Retrospective analysis of pediatric patients who underwent TMVR at Boston Children's Hospital between October 2018 and May 2020 Results: 7 consecutive high surgical risk pediatric patients (median age 9 years, range 8-15) underwent TMVR (6 as ViV, 1 in a native MV). Each patient previously underwent multiple MV surgeries or MVR (median 4, range 2-5) and was highly symptomatic (Ross functional class 3 or 4). The indication for TMVR was mitral stenosis in 5 patients, regurgitation in 1, and mixed disease in 1. TMVR was successful in each patient, effectively reduced the left atrium hypertension (p=0.018), and was carried out without significant complications. Conclusion: Trans-venous trans-catheter mitral valve replacement is an attractive alternative to MVR in high surgical risk patients. In this small series, TMVR was acutely effective and safe, with very encouraging early results.

Outcomes of mitral valve replacement with bileaflet mechanical prosthetic valve in children.

We examined the outcomes following mitral valve replacement with bileaflet mechanical prosthetic valve in children and identified the predictors for mortality and reoperation. Medical records from 49 children who underwent mitral valve replacement between 1982 and 2015 were reviewed retrospectively. Median age and body weight at initial mitral valve replacement were 2.4years and 9.7kg, respectively. The median follow-up was 13years. Surgical results and predictors for mortality and reoperation were investigated. There was no operative mortality; eight late deaths occurred. The actuarial survival rates were 89.5%, 84.2%, and 80.7% at 5, 10, and 15years, respectively, after initial mitral valve replacement. The actuarial freedom rates from related complications were 89.5%, 78.3%, and 70.7% at 5, 10, and 15years, respectively. Nineteen patients required 1st re-mitral valve replacement at a median of 5.9years; six of these 19 required 2nd re-mitral valve replacement at a median of 8.9years after 1st re-MVR. The actuarial freedom rates from re-mitral valve replacement were 86.0%, 56.8%, and 44.2% at 5, 10, and 15years, respectively. No predictor for death was determined; however, the predictor for re-mitral valve replacement was initial valve diameter less than 19mm. Survival outcomes among children after mitral valve replacement with bileaflet mechanical prosthetic valve in biventricular heart were satisfactory. However, complications, including re-mitral valve replacement, were frequent and the predictor was of a small prosthesis size.

Patient-Specific Approach to Mitral Valve Replacement in Infants Weighing 10 kilograms or less.

Mitral valve replacement (MVR) is the only option for infants with severe mitral valve disease that is not reparable; however, previously reported outcomes are not always favorable. Our institution has followed a tailored approach to sizing and positioning of mechanical valve prostheses in infants requiring MVR in order to obtain optimal outcomes. Outcomes for 22 infants ≤10 kg who have undergone MVR in Sydney, Australia, from 1998 to 2016, were analyzed. Patients were at a mean age of 6.8 ± 4.1 months (range: 0.8-13.2 months) and a mean weight of 5.4 ± 1.8 kg at the time of MVR. Most patients (81.8%) had undergone at least one previous cardiac surgical procedure prior to MVR, and 36.4% had undergone two previous procedures. Several surgical techniques were used to implant mechanical bileaflet prostheses. All patients received bileaflet mechanical prostheses, with 12 receiving mitral prostheses and 10 receiving inverted aortic prostheses. Surgical technique varied between patients with valves implanted intra-annularly (n = 6), supra-annularly (n = 11), or supra-annularly with a tilt (n = 5). After a mean follow-up period of 6.2 ± 4.4 years, the survival rate was 100%. Six (27.3%) patients underwent redo MVR a mean of 102.2 ± 10.7 months after initial MVR. Four (18.2%) patients required surgical reintervention for development of left ventricular outflow tract obstruction and three (13.6%) patients required permanent pacemaker placement during long-term follow-up. The tailored surgical strategy utilized for MVR in infants at our institution has resulted in reliable valve function and excellent survival. Although redo is inevitable due to somatic growth, the bileaflet mechanical prostheses used displayed appropriate durability.

Minimally invasive mitral valve repair in Barlow's disease: Early and long-term results

Barlow's disease remains a challenging surgical pathology in patients presenting with mitral regurgitation. We reviewed our early and long-term results for patients with Barlow's disease who underwent minimally invasive mitral valve surgery. Between 1999 and 2010, 145 patients with Barlow's disease underwent minimally invasive mitral valve repair at Leipzig Heart Center. Preoperative echocardiography and intraoperative valve analysis confirmed annular dilatation, bileaflet prolapse, and excessive leaflet tissue in all cases. We retrospectively reviewed mitral valve repair techniques, early and late postoperative clinical outcomes, and follow-up echocardiographic data. Successful mitral valve repair was performed in 94.5% of patients (n=137), initial mitral valve replacement was performed in 2.8% of patients (n=4), and mitral valve replacement after unsuccessful mitral valve repair was performed in 2.8% of patients (n=4). Mean aortic crossclamp time was 99±33 minutes, cardiopulmonary bypass time was 153±47 minutes, and total duration of surgery was 200±44 minutes. Mitral valve repair techniques consisted of ring annuloplasty and a variety of other methods (not mutually exclusive): "loop" neochordae (72% of patients), posterior mitral leaflet resection (28%), Alfieri stitch (17%), commissural plication (9%), chordal transfer (9%), and anterior mitral leaflet resection (7%). Concomitant procedures consisted of cryoablation for atrial fibrillation (28%), tricuspid valve repair (6%), and closure of an atrial septal defect/patent foramen ovale (12%). Thirty-day mortality was 1.4% (n=2), rethoracotomy for bleeding was required in 4.1% of patients (n=6), and conversion to sternotomy was required in 1 patient (0.7%). Long-term clinical follow-up was obtained in 100% of patients, and long-term echocardiographic data were obtained in 93.3% of surviving patients. Long-term survival was 94.7%±2.2% at 5 years and 88.3%±4.9% at 10 years. Freedom from mitral valve reoperation was 96.8%±1.6% at 5 years and 93.8%±2.6% at 10 years. Freedom from greater than 2+ grade mitral regurgitation was 90.2%±3.4% at 5 years and 88.4%±3.9% at 10 years. A wide variety of repair techniques can be used to perform successful minimally invasive mitral valve repair in the majority of patients with Barlow's disease, with good early and long-term results.

Does Metabolic Syndrome Influence Bioprosthetic Mitral Valve Degeneration and Reoperation Rate?

Evidence suggests that metabolic syndrome (MbS) is associated with early senescence of bioprosthetic aortic valve prostheses. The purpose of this study was to determine whether MbS is also associated with accelerated failure of bioprosthetic valves prostheses in the mitral position. Records of all patients undergoing bioprosthetic mitral valve replacement (MVR) from 1993 to 2000 were reviewed. Of 114 patients undergoing bioprosthetic MVR, 48 (42%) had MbS. Mean age was 73 years (vs. 74 years for no MbS). Patients underwent MVR for regurgitation (n = 97; 85%), stenosis (n = 12; 11%), or mixed lesions (n = 4; 4%). Etiology was degenerative (n = 35; 32%), rheumatic (n = 26; 24%), ischemic (n = 30; 28%), calcific (n = 9; 8%), and endocarditis (n = 8; 8%). Mean follow-up was 4.5 years. Overall survival at 5 and 10 years was 56% and 26%, respectively. Survival was similar between groups (p = 0.15). Five patients (2 MbS; 4% vs. 3 no MbS; 5%) required mitral reoperation at a mean of 3.8 years after initial MVR. The risk of prosthetic valve failure was not different between groups (p = 0.66). Despite no initial difference in transmitral gradients, gradients beyond five-year follow-up were greater for those with MbS (6.8 mmHg MbS vs. 4.7 mmHg no MbS, p = 0.007). Independent predictors of gradient progression beyond two years were MbS (p = 0.027) and female gender (p = 0.012). There were no significant differences in valve area, regurgitation, or ejection fraction. Although overall survival following bioprosthetic MVR is challenging, MbS did not predict diminished survival or excess reoperative risk compared to non-MbS patients. The trend toward more rapid progression of transprosthetic gradients in MbS patients warrants further investigation.

Evolution of Mitral Valve Replacement in Children: A 40-Year Experience

This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors. From 1970 to 2010, 97 patients have undergone a total of 136 MVRs. Median age was 8 years (2 weeks to 18 years), 41 patients (42%) were less than 5 years, and 16 were infants (17%). Etiology was congenital in 65 patients (67%), rheumatic in 27 (28%), and endocarditis in 5 (5%). Regurgitation was the predominant lesion in 67 patients (69%), stenosis in 23 (24%), and mixed in 7 (7%) patients. Mechanical valves (ball, n=11; or bileaflet disc, n=66) and xenografts (porcine, n=14; bovine, n=2) were used in 93 initial MVR patients. Since 2002, 5 children have undergone Ross MVR with a pulmonary autograft in 3 and an aortic homograft in 2. Hospital mortality was 6% (6 of 97). There were 23 late deaths and 5 patients have required cardiac transplantation. Thirty-five year actuarial survival was 71%. Age less than 2 years, MVR prior to 1980, atrioventricular septal defect, univentricular heart, and additional left side obstructions were significant predictors of death. Mean follow-up was 12.8±10.1 years (range, 2 months to 38 years). Seventeen patients with mechanical valves experienced systemic emboli in 9 (10%), valve thrombosis in 5 (6%), and bleeding requiring transfusion in 3 (3%) patients. Thirty-two patients required reoperations (35%) from 3 months to 14 years (mean, 6.5±4.4 years) after initial MVR. Actuarial freedom from reoperation at 35 years was 63%. Variables associated with mitral re-replacement were younger age, small weight, valve diameter less than 23 mm, MVR prior to 1980, and type of implanted valves (xenograft, single-leaflet disk, ball-caged, or human valves). Pediatric MVR can be performed with low initial mortality but should be reserved for medical and reconstruction failure because reoperation, valve-related complications, and late mortality are high. Bileaflet prostheses larger than 23 mm have the lowest reoperation risk. Ross MVR may offer select patients a durable tissue valve without lifelong anticoagulation and its associated complications.

Results after mitral valve replacement with mechanical prostheses in young children

We examined outcomes after mitral valve replacement in children younger than 8 years. Medical records of patients who underwent mitral valve replacement from 1990 to 2006 were reviewed. Competing-risks methodology determined time-related prevalence and associated factors for death, repeated valve replacement, and survival without reoperation. In total, 79 patients, median age 24 months (40 days-8 years) underwent 91 mitral valve replacements (10 had repeated procedures). Underlying pathology was congenital heart disease in 95% of cases. Forty-six patients (58%) had undergone previous operations. Operative mortality was 18%, 30% for those 2-years old and younger and 6% for those older than 2 years. Competing-risks analysis showed that 10 years after initial mitral valve replacement, 40% of patients had died without repeated replacement, 20% had undergone a second replacement, and 40% remained alive without further replacement. Factors associated with death included higher prosthesis size/patient weight ratio (P < .0001) and longer crossclamp time (P < .0001). Second replacement 6 +/- 4 years after initial replacement was necessary for 10 survivors. At second replacement, larger prostheses were implanted (mean 24 mm vs 19 mm initially). Repeated MVR was associated with younger age at surgery (p = .006). Permanent pacemaker implantation was eventually needed by 11% of hospital survivors. Mortality and repeated valve replacement are common after mitral valve replacement in children younger than 8 years, especially younger patients with significantly oversized valves. At valve reoperation, larger prostheses could be implanted, suggesting continued annular growth.

Perivalvular leakage 25 years after initial mitral valve replacement with a Björk-Shiley prosthesis

An 80-year-old woman had undergone initial mitral valve replacement using a Björk-Shiley mechanical valve owing to mitral stenosis 25 years earlier. Suddenly, she had anemia and an increased lactic dehydrogenase (LDH) level. Transesophageal echography (TEE) showed perivalvular leakage. In a redo operation, two side-by-side stitches of the valve on the posterior annulus were loosened without cutting and the sewing cuff at that site was floated over the annulus, leading to the perivalvular leakage. The valve was easily removed; and round, hard, degenerative calcified tissue composed of remnant mitral valve in the suture site during the initial operation was found just under the sewing cuff. After resection of this calcified round tissue, a 25-mm bioprosthesis was put in place. Her postoperative recovery was uneventful, and 47 days after surgery she was discharged without perivalvular leakage or anemia.

Current Management of Severe Congenital Mitral Stenosis

Severe congenital mitral stenosis (MS) is a rare anomaly that is frequently associated with additional left heart obstructions. Anatomic treatments for congenital MS include balloon mitral valvuloplasty (BMVP), surgical mitral valvuloplasty (SMVP), and mitral valve replacement (MVR), although the optimal therapeutic strategy is unclear. Between 1985 and 2003, 108 patients with severe congenital MS underwent BMVP or surgical intervention at a median age of 18 months (range 1 month to 17.9 years). Anatomic subtypes of MS were "typical" congenital MS in 78 patients, supravalvar mitral ring in 46, parachute mitral valve in 28, and double-orifice mitral valve in 11, with multiple types in approximately 50% of patients. Additional left heart anomalies were present in 82 patients (76%). The first MS intervention was BMVP in 64 patients, SMVP in 33, and MVR in 11. BMVP decreased peak and mean MS gradients by a median of 33% and 38%, respectively (P<0.001), but was complicated by significant mitral regurgitation in 28%. Cross-sectional follow-up was obtained at 4.8+/-4.2 years. Overall, Kaplan-Meier survival was 92% at 1 month, 84% at 1 year, and 77% at 5 years, with 69% 5-year survival during the first decade of our experience and 87% since (P=0.09). Initial MVR and younger age were associated with worse survival. Survival free from failure of biventricular repair or mitral valve reintervention was 55% at 1 year among patients who underwent BMVP and 69% among patients who underwent supravalvar mitral ring resection initially. Among patients who underwent BMVP, survival free from failure of biventricular repair or MVR was 79% at 1 month and 55% at 5 years, with worse outcome in younger patients and those who developed significant postdilation mitral regurgitation. BMVP effectively relieves left ventricular inflow obstruction in most infants and children with severe congenital MS who require intervention. However, surgical resection is preferable in patients with MS due to a supravalvar mitral ring. Five-year survival is relatively poor in patients with severe congenital MS, with worse outcomes in infants and patients undergoing MVR, but has improved in our more recent experience. Many patients have undergone second procedures for either recurrent/residual MS or mitral regurgitation resulting from dilation-related disruption of the mitral valve apparatus.

Redo Mitral Valve Replacement in Children

Despite excellent results with current techniques of mitral valve repair, some children still require mitral valve replacement (MVR). Of necessity, a certain percentage of these children need valve rereplacement (redo MVR). Of 82 MVRs at our institution since 1988, 22 were redo MVRs in 21 children aged 1.4-21 years (mean 9.8 +/- 5.6 years). Interval from initial MVR was 1 month to 18 years (mean 5.8 +/- 4.9 years). Reoperation indication was primarily stenosis in 13 (usually pannus formation), regurgitation in 4, valve thrombosis or embolism in 4, and endocarditis in 1. The initial valve was mechanical in 18 and xenograft in 4. During redo MVR, 8 of 22 (36%) patients had additional procedures including left ventricular outflow tract obstruction relief or aortic valve replacement in 4 and tricuspid valve repair in 2. The new mitral valve was mechanical in 20 and xenograft in 2. Median valve size increased from 21 mm to 25 mm although 7 valves were not upsized on rereplacement (average valve size increase was 3.3 +/- 1 mm). Only 2 patients (9%) needed a new pacemaker. There were no hospital deaths. Six children developed end-stage heart failure and underwent successful cardiac transplantation 3 to 32 (mean 12.1 +/- 10.0) months, postoperatively. On follow-up of 1 month to 7.7 years (mean 2.5 +/- 2.3 years) there has been only one late death of an unrecognized coronary artery anomaly. Redo MVR in children can be performed safely with low morbidity and mortality. A larger prosthesis can often be placed in these children. A surprisingly high percentage of patients eventually require transplantation, perhaps reflecting unnecessary delay in referral for redo MVR.

Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation

ObjectivesWe sought to characterize the temporal return of mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation; to identify its predictors, particularly with respect to annuloplasty type; and to determine whether annuloplasty type influences survival.MethodsFrom April 1985 through November 2002, 585 patients underwent annuloplasty alone for repair of functional ischemic mitral regurgitation, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove) was used in 68%, a rigid ring (Carpentier) in 21%, and bovine pericardial annuloplasty (Peri-Guard) in 11%. Six hundred seventy-eight postoperative echocardiograms were available in 422 patients to assess the time course of postoperative mitral regurgitation and its correlates. Most echocardiograms were performed early after the operation (median, 8 days); 17% were performed at 1 year or beyond.ResultsDuring the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%, whereas the proportion with 3+ or 4+ regurgitation increased from 13% to 28% (P < .0001); the regurgitation grade was stable thereafter. The temporal pattern of development of 3+ or 4+ regurgitation was similar for Cosgrove bands and Carpentier rings (25%) but substantially worse for Peri-Guard annuloplasties (66%). Small annuloplasty size did not influence postoperative regurgitation grade (P = .2), although Cosgrove bands were used in most patients receiving 26- and 28-mm annuloplasties. Freedom from reoperation was 97% at 5 years. Annuloplasty type was not associated with survival.ConclusionsAlthough initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival. Therefore the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral regurgitation. We sought to characterize the temporal return of mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation; to identify its predictors, particularly with respect to annuloplasty type; and to determine whether annuloplasty type influences survival. From April 1985 through November 2002, 585 patients underwent annuloplasty alone for repair of functional ischemic mitral regurgitation, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove) was used in 68%, a rigid ring (Carpentier) in 21%, and bovine pericardial annuloplasty (Peri-Guard) in 11%. Six hundred seventy-eight postoperative echocardiograms were available in 422 patients to assess the time course of postoperative mitral regurgitation and its correlates. Most echocardiograms were performed early after the operation (median, 8 days); 17% were performed at 1 year or beyond. During the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%, whereas the proportion with 3+ or 4+ regurgitation increased from 13% to 28% (P < .0001); the regurgitation grade was stable thereafter. The temporal pattern of development of 3+ or 4+ regurgitation was similar for Cosgrove bands and Carpentier rings (25%) but substantially worse for Peri-Guard annuloplasties (66%). Small annuloplasty size did not influence postoperative regurgitation grade (P = .2), although Cosgrove bands were used in most patients receiving 26- and 28-mm annuloplasties. Freedom from reoperation was 97% at 5 years. Annuloplasty type was not associated with survival. Although initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival. Therefore the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral regurgitation.

Outcomes of mitral valve replacement in children: A competing-risks analysis

ObjectiveWe sought to define patient characteristics, outcomes, and associated factors after mitral valve replacement in children.MethodsWe included 104 children undergoing at least one mitral valve replacement between 1980 and 2003 and reviewed clinical records. Competing-risks methodology was used to determine time-related prevalence and associated risk factors after initial mitral valve replacement for death and repeat replacement.ResultsThe underlying mitral valve disease was congenital in 83%, rheumatic in 13%, Marfan syndrome in 3%, and isolated endocarditis in 1%, with 64% having primarily regurgitation, 16% having stenosis, 20% having both, and 32% having undergone previous valvotomy, valvuloplasty, or repair. There were 137 valve replacements, with 26 patients having more than one. Valve prosthesis type was St Jude Medical in 37%, Björk-Shiley in 25%, Carbomedics in 20%, Ionescu-Shiley in 10%, and other types in 8%. Both early and late complications were common. Median age at the initial replacement was 5.9 years (range, birth to 19 years). Competing-risks analysis predicted 19% to have died at 15 years after initial replacement, with risk factors including noncongenital valve morphology, lower weight, and longer duration of cardiopulmonary bypass. A repeat replacement was predicted for 71%, with risk factors including the presence of multiple left-heart obstructive lesions and Ionescu-Shiley valve prosthesis.ConclusionsMitral valve replacement might be necessary in children with extremely dysplastic valves and severe hemodynamic impairment or after failed repair. However, with the appropriate selection of the prosthetic valve and reduction of cardiopulmonary bypass time, surgeons might decrease mortality and increase prosthesis longevity. We sought to define patient characteristics, outcomes, and associated factors after mitral valve replacement in children. We included 104 children undergoing at least one mitral valve replacement between 1980 and 2003 and reviewed clinical records. Competing-risks methodology was used to determine time-related prevalence and associated risk factors after initial mitral valve replacement for death and repeat replacement. The underlying mitral valve disease was congenital in 83%, rheumatic in 13%, Marfan syndrome in 3%, and isolated endocarditis in 1%, with 64% having primarily regurgitation, 16% having stenosis, 20% having both, and 32% having undergone previous valvotomy, valvuloplasty, or repair. There were 137 valve replacements, with 26 patients having more than one. Valve prosthesis type was St Jude Medical in 37%, Björk-Shiley in 25%, Carbomedics in 20%, Ionescu-Shiley in 10%, and other types in 8%. Both early and late complications were common. Median age at the initial replacement was 5.9 years (range, birth to 19 years). Competing-risks analysis predicted 19% to have died at 15 years after initial replacement, with risk factors including noncongenital valve morphology, lower weight, and longer duration of cardiopulmonary bypass. A repeat replacement was predicted for 71%, with risk factors including the presence of multiple left-heart obstructive lesions and Ionescu-Shiley valve prosthesis. Mitral valve replacement might be necessary in children with extremely dysplastic valves and severe hemodynamic impairment or after failed repair. However, with the appropriate selection of the prosthetic valve and reduction of cardiopulmonary bypass time, surgeons might decrease mortality and increase prosthesis longevity.

Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation

We sought to characterize the temporal return of mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation; to identify its predictors, particularly with respect to annuloplasty type; and to determine whether annuloplasty type influences survival. From April 1985 through November 2002, 585 patients underwent annuloplasty alone for repair of functional ischemic mitral regurgitation, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove) was used in 68%, a rigid ring (Carpentier) in 21%, and bovine pericardial annuloplasty (Peri-Guard) in 11%. Six hundred seventy-eight postoperative echocardiograms were available in 422 patients to assess the time course of postoperative mitral regurgitation and its correlates. Most echocardiograms were performed early after the operation (median, 8 days); 17% were performed at 1 year or beyond. During the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%, whereas the proportion with 3+ or 4+ regurgitation increased from 13% to 28% ( P < .0001); the regurgitation grade was stable thereafter. The temporal pattern of development of 3+ or 4+ regurgitation was similar for Cosgrove bands and Carpentier rings (25%) but substantially worse for Peri-Guard annuloplasties (66%). Small annuloplasty size did not influence postoperative regurgitation grade ( P = .2), although Cosgrove bands were used in most patients receiving 26- and 28-mm annuloplasties. Freedom from reoperation was 97% at 5 years. Annuloplasty type was not associated with survival. Although initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival. Therefore the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral regurgitation.

Mitral valve replacement in children: Evolution and outcomes of a 40-year experience

Background. The ideal prosthesis for mitral valve replacement (MVR) in children remains controversial. The study aim was to review of evolution and outcomes of our 40-year experience with MVR in children. Methods. Since 1963, 75 patients (mean age 9.2 years) have undergone a total of 103 MVR operations. The etiology for valve disease was congenital in 55% of patients, rheumatic in 35%, endocarditis in 8%, and myxomatous in 2%. Xenograft bioprosthesis ( n = 13) and mechanical valves ( n = 58) were used in 71 patients at initial MVR. Since 2002, four patients have undergone MVR using a pulmonary autograft (Ross MVR). Results. Hospital mortality was 9%. Mean follow-up was 7.8 years (range; 2 months to 30 years). Twenty-three patients required reoperations (34%) after the initial MVR. Actuarial freedom from reoperation at 30 years was 47%. There were 16 late deaths and four patients underwent heart transplantation. Overall 30-year survival was 69%. Mortality for children under 2 years versus over 2 years was 47% versus 26% ( P = 0.02), for atrioventricular septal defect versus other pathology mortality was 54% versus 26% ( P = 0.05), and for those operated before versus after 1980 it was 57% versus 20% ( P = 0.003). Conclusions. MVR is the only surgical option for nonrepairable mitral valve in children. Until recently we have favored mechanical MVR for children with failed reconstructive surgery. Our recent experience with the Ross MVR and aortic homograft MVR has allowed us to offer select patients the possibility of a more durable tissue valve without the need for long-term anticoagulation. The Ross MVR is particularly attractive in young female patients.

Outcomes of mitral valve replacement in children: A competing-risks analysis

We sought to define patient characteristics, outcomes, and associated factors after mitral valve replacement in children. We included 104 children undergoing at least one mitral valve replacement between 1980 and 2003 and reviewed clinical records. Competing-risks methodology was used to determine time-related prevalence and associated risk factors after initial mitral valve replacement for death and repeat replacement. The underlying mitral valve disease was congenital in 83%, rheumatic in 13%, Marfan syndrome in 3%, and isolated endocarditis in 1%, with 64% having primarily regurgitation, 16% having stenosis, 20% having both, and 32% having undergone previous valvotomy, valvuloplasty, or repair. There were 137 valve replacements, with 26 patients having more than one. Valve prosthesis type was St Jude Medical in 37%, Bjork-Shiley in 25%, Carbomedics in 20%, Ionescu-Shiley in 10%, and other types in 8%. Both early and late complications were common. Median age at the initial replacement was 5.9 years (range, birth to 19 years). Competing-risks analysis predicted 19% to have died at 15 years after initial replacement, with risk factors including noncongenital valve morphology, lower weight, and longer duration of cardiopulmonary bypass. A repeat replacement was predicted for 71%, with risk factors including the presence of multiple left-heart obstructive lesions and Ionescu-Shiley valve prosthesis. Mitral valve replacement might be necessary in children with extremely dysplastic valves and severe hemodynamic impairment or after failed repair. However, with the appropriate selection of the prosthetic valve and reduction of cardiopulmonary bypass time, surgeons might decrease mortality and increase prosthesis longevity.

Long-Term Survival After Mitral Valve Replacement in Children Aged &lt;5 Years

Background Short- and long-term outcomes after prosthetic mitral valve replacement (MVR) in children aged &lt;5 years are ill-defined and generally perceived as poor. The experience of the Pediatric Cardiac Care Consortium (45 centers, 1982 to 1999) was reviewed. Methods and Results MVR was performed 176 times on 139 patients. Median follow-up was 6.2 years (range 0 to 20 years, 96% complete). Age at initial MVR was 1.9±1.4 years. Complications after initial MVR included heart block requiring pacemaker (16%), endocarditis (6%), thrombosis (3%), and stroke (2%). Patient survival was as follows: 1 year, 79%; 5 years, 75%; and 10 years, 74%. The majority of deaths occurred early after initial MVR, with little late attrition despite repeat MVR and chronic anticoagulation. Among survivors, the 5-year freedom from reoperation was 81%. Age-adjusted multivariable predictors of death include the presence of complete atrioventricular canal (hazard ratio 4.76, 95% CI 1.59 to 14.30), Shone’s syndrome (hazard ratio 3.68, 95% CI 1.14 to 11.89), and increased ratio of prosthetic valve size to patient weight (relative risk 1.77 per mm/kg increment, 95% CI 1.06 to 2.97). Age- and diagnosis-adjusted prosthetic size/weight ratios predicted a 1-year survival of 91% for size/weight ratio 2, 79% for size/weight ratio 3, 61% for size/weight ratio 4, and 37% for size/weight ratio 5. Conclusions Early mortality after MVR can be predicted on the basis of diagnosis and the size/weight ratio. Late mortality is low. These data can assist in choosing between MVR and alternative palliative strategies.

Long-term survival after mitral valve replacement in children aged

Short- and long-term outcomes after prosthetic mitral valve replacement (MVR) in children aged <5 years are ill-defined and generally perceived as poor. The experience of the Pediatric Cardiac Care Consortium (45 centers, 1982 to 1999) was reviewed. MVR was performed 176 times on 139 patients. Median follow-up was 6.2 years (range 0 to 20 years, 96% complete). Age at initial MVR was 1.9+/-1.4 years. Complications after initial MVR included heart block requiring pacemaker (16%), endocarditis (6%), thrombosis (3%), and stroke (2%). Patient survival was as follows: 1 year, 79%; 5 years, 75%; and 10 years, 74%. The majority of deaths occurred early after initial MVR, with little late attrition despite repeat MVR and chronic anticoagulation. Among survivors, the 5-year freedom from reoperation was 81%. Age-adjusted multivariable predictors of death include the presence of complete atrioventricular canal (hazard ratio 4.76, 95% CI 1.59 to 14.30), Shone's syndrome (hazard ratio 3.68, 95% CI 1.14 to 11.89), and increased ratio of prosthetic valve size to patient weight (relative risk 1.77 per mm/kg increment, 95% CI 1.06 to 2.97). Age- and diagnosis-adjusted prosthetic size/weight ratios predicted a 1-year survival of 91% for size/weight ratio 2, 79% for size/weight ratio 3, 61% for size/weight ratio 4, and 37% for size/weight ratio 5. Early mortality after MVR can be predicted on the basis of diagnosis and the size/weight ratio. Late mortality is low. These data can assist in choosing between MVR and alternative palliative strategies.