Mitral Valve Replacement In Infants Research Articles

Mitral Valve Replacement in Infants and Children: Five-Year Outcomes of the HALO Clinical Trial

BackgroundRepair is preferable for children with mitral valve disease, but mitral valve replacement (MVR) is occasionally necessary. This report presents the results of a multiinstitutional Investigational Device Exemption trial of the 15-mm St Jude (SJM) mechanical mitral valve (Abbott Structural Heart). MethodsFrom May 2015 to March 2017, 23 children aged 0.4 to 27.4 months (mean, 7.8 months; 85% <1 year) weighing 2.9 to 10.9 kg (mean, 5.5 kg) at 15 centers underwent MVR with a 15-mm SJM mechanical mitral valve (intraannular, 45%; supraannular, 55%). A total of 21 (91%) of the children had undergone previous cardiac operations. Follow-up until death, valve explantation, or 5 years postoperatively was 100% complete. ResultsThere were 6 deaths, all in the first 12 months; no death was valve related. Four patients required a pacemaker (2 supraannular, 2 intraannular). Three patients had thrombosis requiring valve explantation at 13, 21, and 35 days postoperatively. Two of these 3 patients were receiving low-molecular-weight heparin for anticoagulation, and the third had factor V Leiden deficiency. There were 5 nonfatal bleeding complications within 4 months of MVR (1-year freedom from bleeding, 71.0%). The 1- and 5-year freedom from death or valve explantation was 71.0%. ConclusionsIn small children with severe mitral valve disease requiring MVR, the 15-mm SJM mechanical mitral valve provides satisfactory hemodynamics. Mortality and complications in these patients are not trivial. Low-molecular-weight heparin likely should be avoided as primary anticoagulation. Eventual valve replacement is inevitable.

Risk of infective endocarditis after hybrid melody mitral valve replacement in infants: the French experience.

Surgical management of mitral valve disease is challenging in infants <1 year old. We aimed at reviewing the French experience with Melody mitral valve replacement in critically ill infants. A retrospective cohort study reporting the French experience with Melody mitral valve replacement. Seven symptomatic infants [complete atrioventricular septal defect (n = 4, Down syndrome: n = 3), hammock valve (n = 3)] underwent Melody mitral valve replacement [age: 3 months (28 days to 8 months), weight: 4.3 kg (3.2-6.4 kg)] because of severe mitral valve regurgitation (6) or mixed valve disease (1) and 14 mm (11-16 mm) mitral valve annulus. In 2 patients whose valve was felt irreparable, Melody mitral valve replacement was performed straightaway. The others underwent 2 (1-3) previous attempts of valve repair; 3 were on extracorporeal membrane oxygenation. Melody mitral valve replacement led to competent valve and low gradient [3 mmHg, (1-4 mmHg)]. One patient died 3 days post-implant from extracorporeal membrane oxygenation-related stroke. Of the 6 discharged home patients, 3 (50%) were readmitted for a definite diagnosis (1) or high suspicion (2) of infective endocarditis, of which 2 died. Over the follow-up, 1 underwent balloon expansions of the valve at 9- and 16-months post-implant, and mechanical mitral valve replacement at 2 years; another is currently planned for transcatheter Melody valve dilation. Melody mitral valve replacement may be considered in selected infants with small mitral valve annulus as an alternative to mechanical mitral valve replacement. Our experience highlights a high-risk of late infective endocarditis that deserves further consideration.

Risk of infective endocarditis after hybrid Melody mitral valve replacement in infants: The French experience

Risk of infective endocarditis after hybrid Melody mitral valve replacement in infants: The French experience

Between a Rock and a Hard Place—Challenges of Mitral Valve Replacement in Infants

Mitral Valve Replacement in Infants and Children: Experience Using a 15-mm Mechanical ValveThe Annals of Thoracic SurgeryPreviewReports using a 15-mm mechanical valve for mitral valve replacement (MMVR) in children are limited. We review our center's operative and postoperative experience with this valve. Full-Text PDF

Surgical Mitral Valve Replacement Using a Catheter-Based MelodyTM Valve in a Landing Zone Constructed With a PTFE-Covered Expandable Cheatham-PlatinumTM Stent.

Mitral valve replacement using a Melody valve is a promising solution to the challenge of surgical mitral valve replacement in infants with a hypoplastic annulus. We report the creation of a landing zone in the mitral valve annulus using a Cheatham-Platinum (CP)-covered stent that facilitates Melody valve placement, helps prevent paravalvular leak, minimizes left ventricular outflow tract obstruction, and allows for potential future dilation of the valve.

An alternative valve for mitral valve replacement in young children: using an NO-REACT® INJECTABLE BIOPULMONIC™ prosthesis as a mitral valve replacement in a 14-month-old child.

Mitral valve replacement in infants is challenging and there are limited alternative valves available. Since the Boston group published their first report on alternative valves for mitral valve replacement in infants, there has been a growth in the literature on the topic, mostly based on the use of a stented bovine jugular vein graft (Melody® valve). The challenges of the Melody valve are firstly in its length of 28 mm unexpanded, which has the potential to cause left ventricular outflow tract obstruction, and secondly, the valve needs mechanical dilatation, which is laborious. A modified No-React® Injectable Biopulmonic™ Prosthesis (Bio Integral Surgical, Inc., Mississauga, ON, Canada) which is shorter (19 mm) and simpler in that it is self-expanding was implanted in a 14-month-old child to replace her mitral valve. The operation was successful and the short-term function of the prosthesis is good.

Mitral valve replacement in infants and younger children

Data on mitral valve replacement (MVR) in young children is still limited. Our objective was to evaluate MVR in children below 5 years and identify factors affecting the outcomes. This retrospective study included 29 patients who had MVR from 2002 to 2020. We grouped the patients into two groups according to their age: age ≤ 24 months (n = 18) and > 24 months (n = 11). Primary cardiac diagnoses were Shone complex (n = 7; 24%), isolated congenital mitral valve abnormality (n = 11; 38%), and complete atrioventricular septal defect (n = 3; 10%). The median age was 19 month (25th–75th percentile: 11–32) and 59% were females (n = 17). The hemodynamic lesions were mitral regurgitation in 66%, mitral stenosis in 10%, and combined mitral stenosis and regurgitation in 24% of the patients. St. Jude mitral valve was the most common valve implanted (n = 19, 66%), followed by CarboMedics in 21% of the patients (n = 6). The mitral valve was implanted in the supra-annular position in 6 cases (21%). Preoperative and operative data were comparable between both groups. There was no association between valve size and position with postoperative heart block (P > 0.99, for both). The median follow-up duration was 19.4 months (8.6–102.5). Nine patients had mitral valve reoperation, six had MVR, and three had clot removal from the mitral valve. There was no effect for age group on reoperation (SHR 0.89 (95% CI 0.27–2.87), P = 0.84). Valve size significantly affected reoperation (SHR 0.39 (95% CI 0.18–0.87), P = 0.02). The supra-annular position was associated with an increased risk of reoperation (SHR 3.1 (95% CI 1.003–9.4), P = 0.049). There was no difference in survival according to the age (Log-rank P = 0.57) or valve size (Log-rank P = 0.66). Mitral valve replacement in children is associated with low morbidity and mortality. The risk of reoperation could be affected by the valve size and position rather than the age.

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.

Mitral valve replacement in infants.

Mitral valve replacement in infants.

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.

Modified technique for Melody valve implantation in the mitral position

Modified technique for Melody valve implantation in the mitral position

Melody Valve for Mitral Valve Replacement

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.

Stented bovine jugular vein graft (Melody valve) for surgical mitral valve replacement in infants and children

The options for mitral valve replacement in children with irreparable mitral valve disease have been limited to fixed-diameter prostheses that do not accommodate for somatic growth. We have modified an externally stented bovine jugular vein graft (Melody valve) for implantation in this cohort. Because it is not a fixed-diameter prosthesis, we hypothesized that the valve can be expanded in the catheterization laboratory as the child grows. The medical records of patients who had undergone Melody valve implantation in the mitral or left atrioventricular valve position from 2010 to 2013 were reviewed. Eleven patients had undergone Melody valve implantation at a median age of 7 months (range, 2-28). The techniques of valve modification and implantation included stent shortening, adding a pericardial sewing cuff, intraoperative balloon expansion, and fixation of the distal stent to the inferior left ventricle wall. The valve was competent, with a low gradient acutely postoperatively in all patients. One patient died, and one required permanent pacemaker implantation. One patient developed valve dysfunction and required explantation. Two patients without a pericardial sewing cuff developed paravalvular leaks. One patient who had not undergone distal stent fixation developed left ventricular outflow tract obstruction. Three patients who had undergone subsequent catheter-based balloon expansion of the valve have continued to demonstrate acceptable valvular function. The Melody valve has demonstrated acceptable short-term function. Implantation techniques to prevent left ventricular outflow tract obstruction (suture fixation of the distal stent) and paravalvular leaks (theaddition of a pericardial cuff) should be considered. The Melody valve can be percutaneously expanded as the child grows.

Mitral valve replacement in infants and children 5 years of age or younger: Evolution in practice and outcome over three decades with a focus on supra-annular prosthesis implantation

Mitral valve replacement in infants and children 5 years of age or younger: Evolution in practice and outcome over three decades with a focus on supra-annular prosthesis implantation

Ross-Kabbani Operation in an Infant with Mitral Valve Dysplasia

Background. Mitral valve replacement can be very difficult to obtain in infants because the valve annulus diameter can be smaller than the available prosthesis. Case Report. We describe the case of a 2-month-old female weighing 3.5 kg affected by mitral valve dysplasia leading to severe valve stenosis. Despite full medication, the clinical conditions were critical and surgery was undertaken. The mitral valve was unsuitable for repair and the orifice of mitral anulus was 12 mm, too small for a mechanical prosthesis. Therefore, a Ross-Kabbani operation was undertaken, replacing the mitral valve with the pulmonary autograft and reconstructing the right ventricular outflow tract with an etherograft. Results. The postoperative course was uneventful and the clinical conditions are good at 4-month follow-up. Conclusion. The Ross-Kabbani operation can be an interesting alternative to mitral valve replacement in infants when valve repair is not achievable and there is little space for an intra-annular mechanical prosthesis implant.

Mitral valve replacement in infants and children 5 years of age or younger: Evolution in practice and outcome over three decades with a focus on supra-annular prosthesis implantation

Successful mitral valve replacement in young children is limited by the lack of small prosthetic valves. Supra-annular prosthesis implantation can facilitate mitral valve replacement with a larger prosthesis in children with a small annulus, but little is known about its effect on the outcomes of mitral valve replacement in young children. One hundred eighteen children underwent mitral valve replacement at 5 years of age or younger from 1976-2006. Mitral valve replacement was supra-annular in 37 (32%) patients. Survival was 74% +/- 4% at 1 year and 56% +/- 5% at 10 years but improved over time (10-year survival of 83% +/- 7% from 1994-2006). Factors associated with worse survival included earlier mitral valve replacement date, age less than 1 year, complete atrioventricular canal, and additional procedures at mitral valve replacement, but not supra-annular mitral valve replacement. As survival improved during our more recent experience, the risks of supra-annular mitral valve replacement became apparent; survival was worse among patients with a supra-annular prosthesis after 1991. A pacemaker was placed in 18 (15%) patients within 1 month of mitral valve replacement and was less likely in patients who had undergone supra-annular mitral valve replacement. Among early survivors, freedom from redo mitral valve replacement was 72% +/- 5% at 5 years and 45% +/- 7% at 10 years. Twenty-one patients with a supra-annular prosthesis underwent redo mitral valve replacement. The second prosthesis was annular in 15 of these patients and upsized in all but 1, but 5 required pacemaker placement for heart block. Supra-annular mitral valve replacement was associated with worse survival than annular mitral valve replacement in our recent experience. Patients with supra-annular mitral valve replacement were less likely to have operative complete heart block but remained at risk when the prosthesis was subsequently replaced.

Mechanical Aortic and Mitral Valve Replacement in Infants and Children

The aim of this study was to evaluate early and late outcomes after mechanical systemic heart valve replacement in pediatric patients. Between October 1981 and December 2003, 32 children (mean age 7.2 +/- 5.4 years; 4 months - 15.9 years) underwent mechanical mitral (MVR, n = 17), aortic (AVR, n = 13) or double valve replacement (DVR, n = 2) with St. Jude Medical valves. Twenty-two patients (69 %) had undergone previous cardiac surgery. Anticoagulation self-management was used since 1995. The operative mortality was 3.1 %. Perioperative complications were complete heart block (n = 5), ventricular fibrillation (n = 1) and myocardial infarction (n = 1) and were exclusively related to patients with MVR. Mean calculated valve size ratio (geometric prosthesis orifice area/normal valve size area) was 1.72 (1.07 - 2.85) for AVR and 1.4 (0.88 - 3.12) for MVR. Mean follow-up was 9.1 +/- 6.6 years (range 0.4 - 23.2 years, cumulative 283 patient-years). There were two late deaths in patients with MVR. Actuarial survival after 10 years was 93.8 %. Late complications were endocarditis (n = 2), minor hemorrhagic event (n = 1), and stroke (n = 1). Anticoagulation self-management is well accepted by all patients/parents. Overall 10-year freedom from any anticoagulation-related adverse event with phenprocoumon was 89.1 % (1.2 %/patient year). Nine patients required reoperations: redo-MVR (outgrowth of prostheses (n = 3), pannus overgrowth (n = 2), closure of paravalvular leak after AVR (n = 2), partial aortic valve thrombosis (n = 1) and redo-DVR (n = 1 for endocarditis). Freedom from reoperation after 10 years was 80.9 %. Mechanical valve prostheses are a valuable option for left-sided heart valve replacement in pediatric patients. Perioperative morbidity was exclusively related to patients with MVR. Oversizing was often possible to avoid early reoperation for outgrowth. The operative mortality and long-term morbidity are acceptable. Anticoagulation self-management is safe and well accepted.

Pulmonary Autograft for Mitral Valve Replacement in Infants: The Ross-Kabbani Operation

We describe the cases of 2 infants aged 6 and 2 1/2 months, respectively, affected by mitral valve dysplasia that caused severe valvular insufficiency and heart failure in which a surgical correction was indicated because of critical general conditions. In both patients the anatomic characteristics of the valves were not suitable for repair, and an implant of a mechanical prosthesis was excluded because of the very young age of the infants and the impossibility of maintaining an adequate anticoagulant therapy. Therefore a Ross-Kabbani intervention was performed with an implant of a pulmonary autograft (in the mitral position) and an insertion of a pulmonary homograft. The postoperative course was free of major complications and good function of the autograft was present at short-term follow-up in both cases.

Clinical Course and Hemodynamic Observations After Supraannular Mitral Valve Replacement in Infants and Children

Objectives. We report the clinical course and unique hemodynamic findings after placement of a supraannular mitral valve prosthesis.Background. Children with symptomatic mitral valve disease whose annulus is too small for the smallest prosthesis are difficult to manage. One option is valve replacement with a prosthesis positioned entirely within the left atrium (LA).Methods. We reviewed 17 patients (median age 10 months) with symptomatic mitral valve disease who underwent placement of a supraannular valve prosthesis between 1980 and 1994.Results. The actuarial survival rates were 88% at 1 month and 71%, 62% and 53% at 1, 2 and 10 years, respectively. Preoperative hemodynamic data (mean ± SD) compared with those after placement of the supraannular mitral prosthesis were as follows: “a” wave to left ventricular end-diastolic pressure gradient 17 ± 5 versus 4 ± 4 mm Hg (p = 0.003), mean LA pressure 25 ± 6 versus 20 ± 6 mm Hg (p = 0.07), “a” wave 30 ± 6 versus 19 ± 5 mm Hg (p = 0.006), “v” wave 28 ± 5 versus 30 ± 9 mm Hg (p = 0.31), mean pulmonary artery pressure 54 ± 19 versus 42 ± 15 mm Hg (p = 0.07) and left ventricular end-diastolic pressure 14 ± 5 versus 16 ± 4 mm Hg (p = 0.12).Conclusions. Supraannular mitral valve replacement provides relief of mitral stenosis or mitral regurgitation. However, LA to left ventricular early diastolic gradients with large atrial “v” waves contribute to elevated mean LA pressures in the absence of prosthetic valve obstruction or regurgitation. As a result of this unexpected finding, associated left heart obstructive lesions and pulmonary and left ventricular end-diastolic hypertension, the outlook remains poor.(J Am Coll Cardiol 1997;29:1089–94)© 1997 by the American College of Cardiology

Mitral Valve Replacement in Infants and Children

Thirteen patients, ranging in age from 10 months to 19 years (mean 7.8 years) and in weight from 6.6 to 60 kg (average 29.5 kg) underwent 14 operations for mitral valve replacement with a heterograft prosthesis between January 1, 1976 and July 1, 1979 for a variety of congenital or acquired lesions. Preoperative indications included severe refractory congestive heart failure in each patient with growth retardation, which was especially prominent in the younger patients. Operative mortality was 14% (2/14) with both deaths occurring within 48 hours of operation in patients less than 6 years of age. All surgical survivors had clinical improvement as manifested by relief of symptoms, decrease in heart size, and significant growth. Routine postoperative catheterization in five patients revealed good initial postoperative results in those studied, with one patient having a second study 20 months after operation. He was found to have had degeneration of his bovine prosthesis and had subsequent successful reoperation with a porcine prosthesis. Further long-term serial catheterizations are needed to further document the history of heterograft prosthesis in children, but they are preferred to mechanical valves became of the lack of need for long-term anticoagulants and the absence of thromboembolism complications. This series suggests that mitral valve replacement, when indicated by refractory congestive heart failure and growth retardation, can be successfully performed even in infants and small children. Surgery should not be postponed to allow for subsequent patient growth if the natural history of the disease is of progression.