Replacement In Children Research Articles

Valve-Sparing Aortic Root Replacement in Children and Adolescents: Experience and Outcomes in a Public Institution in Argentina

Background: Valve-sparing aortic root replacement (VSARR) with reimplantation technique is indicated in patients with aortic root aneurysm. We evaluated the mid-term outcomes of this surgical technique in children and adolescents in our institution. Methods: Retrospective study. Twenty-one patients who underwent VSARR surgery were included between July 2006 and July 2022. The relationship between baseline variables and progression of aortic regurgitation (AR) was assessed. Results: The median age was 13 years. Seventeen patients had connective tissue disorders (3 with bicuspid aortic valve), 2 operated congenital heart disease, 1 isolated bicuspid aortic valve and 1 Turner syndrome. Thirteen patients had mild AR and 5 had moderate AR preoperatively. Three patients underwent early aortic replacement, 2 due to endocarditis and 1 due to severe acute AR. The median follow-up was 4.1 years. Of 17 patients at follow-up, 2 developed mild-moderate AR, 2 moderate AR and 3 severe AR. One of them underwent Bentall surgery. No association was found between the degree of preoperative AR or the presence of bicuspid aortic valve and the progression of postoperative AR. There was no association between the type of postoperative valve coaptation and the development of AR greater than mild at follow-up. Conclusions: VSARR with reimplantation is a feasible surgical technique with favorable mid-term outcomes and low reoperation rate in pediatric patients.

Outcomes after Mechanical Aortic Valve Replacement in Children with Congenital Heart Disease.

The optimal choice of valve substitute for aortic valve replacement (AVR) in pediatric patients remains a matter of debate. This study investigated the outcomes following AVR using mechanical prostheses in children. Forty-four patients younger than 15 years who underwent mechanical AVR from March 1990 through March 2023 were included. The outcomes of interest were death or transplantation, hemorrhagic or thromboembolic events, and reoperation after mechanical AVR. Adverse events included any death, transplant, aortic valve reoperation, and major thromboembolic or hemorrhagic event. The median age and weight at AVR were 139 months and 32 kg, respectively. The median follow-up duration was 56 months. The most commonly used valve size was 21 mm (14 [31.8%]). There were 2 in-hospital deaths, 1 in-hospital transplant, and 1 late death. The overall survival rates at 1 and 10 years post-AVR were 92.9% and 90.0%, respectively. Aortic valve reoperation was required in 4 patients at a median of 70 months post-AVR. No major hemorrhagic or thromboembolic events occurred. The 5- and 10-year adverse event-free survival rates were 81.8% and 72.2%, respectively. In univariable analysis, younger age, longer cardiopulmonary bypass time, and smaller valve size were associated with adverse events. The cut-off values for age and prosthetic valve size to minimize the risk of adverse events were 71 months and 20 mm, respectively. Mechanical AVR could be performed safely in children. Younger age, longer cardiopulmonary bypass time and smaller valve size were associated with adverse events. Thromboembolic or hemorrhagic complications might rarely occur.

Hip Replacement in Children with Femoral Head Collapse and Hip Joint Degeneration—Two Case Reports

There are several pathological conditions in children, such as Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, and femoral head avascular necrosis, which can progress to disabling hip joint destruction. These children undergo surgeries, such as hip arthrodesis, in an attempt to postpone hip replacement so that it can be done at an older age. Unfortunately, hip arthrodesis significantly limits their ability to actively engage in activities that require full hip mobility. For these children, active participation in games and sports activities remains an important factor for their physical development and mental health. On the contrary, hip arthroplasty can ensure a pain-free, unrestricted range of hip movement, but are doubts as to its viability over time, especially in young people who exhibit intense activity. We report successful hip replacement in two children, fourteen years of age and younger, with femoral head collapse and disabling joint degeneration due to avascular necrosis of the femoral head, whom the hip replacement was considered the only surgical treatment ensuring a painless hip joint. For the clinical assessment of these two hips, we used the online Harris hip score, preoperatively and postoperatively. No intraoperative or early postoperative complications occurred. Follow-up was conducted at six weeks, six months, and then at an annual clinical and radiological evaluation. At the final seven-year follow-up, these two children had greatly improved their function hip score considerably. Hip arthroplasty can ensure a pain-free, unrestricted range of hip movement in young children when their hip joint is severely affected.

Outcomes Following Aortic Valve Replacement in Children With Conotruncal Anomalies.

Conotruncal anomalies can develop aortopathy and/or aortic valve (AV) disease and AV replacement (AVR) is occasionally needed. We report long-term results and examine factors affecting survival following AVR in this group. We queried the Pediatric Cardiac Care Consortium (PCCC, US database for interventions for congenital heart diseases) to identify patients with repaired conotruncal anomalies and AVR. Long-term outcomes were provided by the PCCC, the US National Death Index, and Organ Procurement and Transplantation Network. Competing risks analysis examined outcomes following AVR (death/transplantation, reoperation) and multivariable regression analysis assessed significant factors. One hundred six children with repaired conotruncal anomalies underwent AVR (1982-2003). Underlying anomaly was truncus (n = 40), d-transposition (n = 22), type-B interrupted arch (n = 16), double-outlet right ventricle (n = 12), pulmonary atresia with ventricular septal defect (n = 9), tetralogy of Fallot (n = 6), corrected transposition (n = 1). 18 (17%) had prior aortic valvuloplasty (surgical = 12, percutaneous = 6). Median age at AVR was 6.9 years (interquartile range = 2.5-12.4). AV pathophysiology was regurgitation (n = 83, 78%), stenosis (n = 9, 9%), and mixed (n = 14, 15%). AVR type was mechanical (n = 72, 68%), homograft (n = 21, 20%), and Ross (n = 13, 12%). Operative mortality was 13(12%). Infant age at AVR was risk factor (odds ratio = 55, 95% confidence interval [CI] = 6-539, P = .0006). On competing risks analysis, five years after AVR, 6% died or received transplantation, 20% had reoperation. Twenty-five years transplant-free survival was 53%. Factors associated with death after hospital discharge included mitral surgery (hazards ratio [HR] = 11, 95% CI = 3-39, P = .0002), underlying defect (HR = 2, 95% CI = 1-5, P = .446). Twenty years transplant-free survival in conotruncal anomalies group was inferior to matched children undergoing AVR for congenital non-conotruncal disease (61% vs 82%, P = .0012). Long-term survival following AVR in children with conotruncal anomalies is inferior to that of isolated congenital AV disease and is linked to an underlying cardiac defect. Although valve type was not associated with survival, infant age was a risk factor for operative mortality. Continuous attrition and high reoperation warrant vigilant monitoring.

Abstract 10390: Transcatheter and Surgical Aortic Valve Replacement in Children with Congenital Heart Disease: An Institutional Experience

Introduction: Surgical approaches have historically been the mainstay for aortic valve replacement in children and adults, while transcatheter approaches have been increasingly utilized in adults with rare use in children. We hypothesized that short-term outcomes for native aortic valve replacement are comparable between the surgical (SAVR) or transcatheter (TAVR) approach in children. Methods: Patients < 21 years who had native SAVR or TAVR between January 2010 to April 2020 at our institution were included. Analysis focused on short-term outcomes for ages 10-21. SAVR and TAVR were compared using a composite outcome score (stroke within 6 months, readmission within 30 days, death). Pre- and post-procedural characteristics were compared using chi-squared test or Wilcox rank sum test as appropriate. Results: Of 77 patients included, 46 were 10-21 yrs (30 SAVR, 16 TAVR). Mean follow-up was 3.7 yrs for the SAVR group and 1.7 yrs for the TAVR group. There was no significant difference in the composite score between groups (3 SAVR, 2 TAVR; p = 1). Patients in the SAVR group were more likely to have undergone concomitant surgical intervention (e.g., Konno procedure, mitral valve repair/replacement, etc.) and have longer hospital stays (Table 1). Death in the SAVR group was secondary to patient non-compliance with recommended medications and follow-up, resulting in severe aortic stenosis with cardiogenic shock and respiratory failure. Death in the TAVR group was secondary to endocarditis of the valve and associated stroke, which converted from ischemic to hemorrhagic following surgical intervention. Conclusion: Our study suggests similar short-term outcomes for TAVR and SAVR in children and young adults > 10 years of age. Long-term studies are essential in the pediatric population to fully explore the option of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement.

Cementless Ceramic-on-Ceramic Total Hip Replacement in Children and Adolescents.

Background: total hip replacement (THR) is a rare surgical option in children and adolescents with disabling hip diseases. The aim of this study is to report results from a retrospective cohort of patients aged 18 years or less who underwent cementless Ceramic-on-Ceramic (CoC) THR at a single institution, investigating clinical and radiographic outcomes, survival rates, and reasons for revision of the implants. Materials and methods: we queried the Registry of Prosthetic Orthopedic Implants (RIPO) to identify all children and adolescents undergoing THR between 2000 and 2019 at a single Institution. Inclusion criteria were patients undergoing cementless CoC THR, aged less than 18 years at surgery, followed for at least 2 years. Sixty-eight patients (74 hips) matched all the inclusion criteria and were enrolled in the study. We assessed the clinical and radiographic outcomes, the rate of complications, the survival rate, and reasons for revision of the implants. Results: The mean follow-up was 6.6 ± 4.4 years (range 2–20). The most frequent reason for THR was post-traumatic or chemotherapy-induced avascular necrosis (38%). The overall survival rate of the cohort was 97.6% (95% CI: 84.9–99.7%) at 5 years of follow-up, 94.4% (95% CI: 79.8–98.6%) at 10 years and 15 years of follow-up. Two THR in two patients (2.7%) required revision. With the numbers available, Cox regression analysis could not detect any significant interaction between preoperative or intraoperative variables and implant survivorship (p-value 0.242 to 0.989).” The average HOOS was 85 ± 14.3 (range 30.6–100). Overall, 23 patients (48%) reported excellent HOOS scores (>90 points), 21 patients (44%) reported acceptable HOOS scores (60–90 points) while 4 patients (8%) reported poor outcomes (<60 points). Twenty-one patients (43%) were regularly involved into moderate- to high-intensity sport activities (UCLA ≥ 6). Conclusions: Cementless CoC THR is a successful procedure in children and teenagers, having demonstrated high implant survivorship and low rates of complications and failure. A meticulous preoperative planning and implant selection is mandatory, to avoid implant malposition, which is the main reason of failure and revision in these cases. Further studies are needed to assess the impact of the THR on the psychosocial wellbeing of teenagers, as well as risks and benefits and cost-effectiveness in comparison to the hip preserving surgical procedures.

What Factors Should Be Considered to Improve Outcome of Mechanical Mitral Valve Replacement in Children?

To identify risk factors for pediatric mechanical mitral valve replacement (mMVR) to improve management in this challenging population. From 1993 to 2019, 93 children underwent 119 mMVR operations (median age, 8.8 years [interquartile range [IQR]: 2.1-13.3], 54.6% females) at our institution. Twenty-six (21.8%) patients underwent mMVR at ≤2 years and 93 (78.2%) patients underwent mMVR at >2 years. Median follow-up duration was 7.6 years [IQR: 3.2-12.4]. Early mortality was 9.7%, but decreased with time and was 0% in the most recent era (13.9% from 1993 to 2000, 7.3% from 2001 to 2010, 0% from 2011 to 2019, P = .04). It was higher in patients ≤2 years compared to patients >2 years (26.9% vs 2.2%, P < .01). On multivariable analysis for mitral valve reoperation, valve size <23 mm was significant with a hazard ratio of 5.38 (4.87-19.47, P = .01);. Perioperative stroke occurred in 1% and permanent pacemaker was necessary in 12%. Freedom from mitral valve reoperation was higher in patients >2 years and those with a prosthesis ≥23 mm. Median time to reoperation was 7 years (IQR: 4.5-9.1) in patients >2 years and 3.5 years (IQR: 0.6-7.1) in patients ≤2 years (P = .0511), but was similar between prosthesis sizes (P = .6). During follow-up period (median 7.6 years [IQR: 3.2-12.4], stroke occurred in 10%, prosthetic valve thrombosis requiring reoperation in 4%, endocarditis in 3%, and bleeding in 1%. Early and late outcomes of mMVR in children are improved when performed at age >2 years and with prosthesis size ≥23 mm. These factors should be considered in the timing of mMVR.

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

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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.

Current Treatment Options for Catheter-Based Pulmonary Valve Replacement in Children

For decades, surgical replacement of the pulmonary valve has been the gold standard. The last 10 years have seen significant progress in improvement in the technology and techniques around percutaneous pulmonary valve Percutaneous pulmonary valve replacement (PPVR). This has allowed us to expand the range of patients who can be treated with percutaneous techniques. This review serves as an update for referring cardiologists. Several studies have demonstrated similar clinical outcomes comparing surgical and percutaneous valve replacement, noting the decreased recovery time and morbidity after PPVR. Along with the overall periprocedural advantages of PPVR, newer devices now allow pulmonary valve replacement in patients with surgically placed conduits and in patients with dilated native right ventricular outflow tracts (RVOT). PPVR is now also performed in smaller patients thanks to newly available techniques and technology. Imaging technology to guide these procedures has also evolved allowing such complex interventions to be performed with minimal radiation and contrast use in the catheterization laboratory. knowledge of technological advancements in PPVR will allow referring cardiologists and patients to make informed decisions about pulmonary valve replacement in each individual case. Technology will continue to evolve and hopefully provide many more surgical and percutaneous options to care for the congenital heart disease population.

Sodium Status and Replacement in Children and Adults Living with Cystic Fibrosis: A Narrative Review

Patients with cystic fibrosis (CF) have a two- to four-fold higher sodium chloride sweat content compared with healthy controls. This high sweat salt loss increases the risk for electrolyte disturbances, associated with subacute or chronic complications. Sodium status therefore needs to be adequately monitored and salt intake adjusted to individual needs. The lack of current evidence to formulate specific recommendations and assess sodium status is reflected in a variability of recommendations in international guidelines. This narrative review presents an overview of the current evidence. Infants with CF in particular are at risk for severe sodium deficiency, potentially leading to metabolic alkalosis due to low intake and high sweat losses. More research on the assessment of sodium status and efficacy of sodium chloride supplements in the population of patients with CF, especially given the changing era of CF transmembrane conductance regulator modulatory treatment, is warranted.

30-Day Outcomes Following Esophageal Replacement in Children: A National Surgical Quality Improvement Project Pediatric Analysis

IntroductionThe optimal method of esophageal replacement remains controversial. The aim of this study was to evaluate 30-d outcomes of children in the National Surgical Quality Improvement Project Pediatric (NSQIP-P) database who underwent esophageal replacement from 2012 to 2018. MethodsDemographics, comorbidities, and procedural technique was identified in NSQIP-P and reviewed. Thirty-day outcomes were assessed and stratified by gastric pull-up or tube interposition versus small bowel or colonic interposition. Categorical and continuous variables were assessed by Pearson's chi-square, Fisher's exact, and Wilcoxon rank-sum tests, respectively. Multivariate logistic regression was performed to estimate the effects of procedure technique and clinical risk factors on patient outcomes. ResultsOf the 99 cases of esophageal replacement included, 52 (52.5%) utilized a gastric conduit, whereas 47 (47.5%) involved small bowel/colonic esophageal interposition. Overall risk of complications was 52.5%, the most common of which were perioperative transfusion (30.3%), surgical site infection (11.1%), and sepsis (9.1%). Risk of unplanned reoperation was 17.2%, and risk of mortality was 3.0%. Risk for complications, reoperation, and readmission did not differ significantly between those who underwent gastric esophageal replacement and those who underwent small bowel or colonic interposition. Median operative time was shorter in the gastric esophageal replacement group (5.2 versus 8.1 h, P = 0.009). ConclusionsAmong children in NSQIP-P who underwent esophageal replacement from 2012 to 2018, the risk of 30-d complications, unplanned reoperation, and mortality was relatively frequent and was similar across operative techniques. Opportunities exist to improve preoperative optimization, utilization of blood transfusion services, and infectious complications in the perioperative period irrespective of operative technique. Level of evidenceLevel III, retrospective comparative study.

What is the Best Choice for Esophageal Replacement in Children?

Esophageal replacement surgery is performed in children with either congenital long gap esophageal atresia or acquired esophageal damages such as caustic injury of the esophagus. although the left colon because of less variation in blood supply and suitable diameter in comparison with right colon is the better choice. A secured pedicled colon is mandatory for reducing the sever complications, such as leak and necrosis. Ileocolic conduit is an alternative method of colon interposition which has anti reflux effect and therefore with less complications related to gastroesophageal reflux. When we have a short segment esophageal stricture due to corrosive esophagitis or other causes of esophageal strictures which is refractory to repeated dilatations, it is advisable to perform colon patch esophagoplasty. Gastric transposition can produce a good way for gastrointestinal continuity with a perfect weight gain and oral feeding, therefor it can be a safe choice for esophageal replacement in children. Partial gastric pull-up is an alternative operation for esophageal replacement in children and infants with long gap esophageal atresia. Gastric conduit replacement is another alternative technique for esophageal replacement, in which a gastric tube is created in the abdomen and it is pulled to via thoracic cavity to the neck and is committed by cervical anastomosis. Antral patch esophagoplasty is used for benign and limited esophageal stricture due to gastroesophageal reflux. Usefulness of pedicled jejunum was under optimal results because of technical problems and high rate of necrosis and mortality for decades. Sternocleidomastoid myocutaneous esophagoplasty is a scarce method which is reported by some surgeons for limited cervical esophageal stricture repair. Free microvascular transfer of the reverse ileo-colon flap with ileocaecal valve valvuloplasty is used for reconstruction of a pharyngoesophageal defect, and Patch esophagoplasty by using of degradable bioscaffolds of extracellular matrix have shown good results in preclinical and clinical outcomes to prevent stenosis after endoscopic mucosectomy. We will explain the advantages and disadvantages of these different surgical methods in this review article.

Second Allogeneic Hematopoietic Stem Cell Transplantation After Donor Replacement in Children With Severe Aplastic Anemia

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective measure for the treatment of severe aplastic anemia (SAA). While infection, graft failure, and graft-vs-host disease (GVHD) are the main causes of allo-HSCT failure, a second HSCT is needed to eliminate the dependence of blood transfusion and maintain disease-free survival. We applied low-dose total body irradiation (TBI) + fludarabine (FLU) + cyclophosphamide (CTX) + antilymphocyte globulin (ALG) + busulfan (BU) as a conditioning regimen of second HSCT after a transplantation with an HLA-mismatched donor. As for retransplantation donors, 1 child had an unrelated HLA-matched donor, and 2 children had related HLA-mismatched ones. The latter underwent more serious GVHD with a relatively high cytokine level, and the former had no obvious GVHD after the second HSCT. All 3 patients achieved a desirable effect within 1 month and received satisfactory therapeutic effect during the subsequent follow-up, indicating the convincing effectiveness and safety of this method.

Valve Replacement in Children with Single Ventricle Physiology.

Severe atrioventricular valve (AVV) or semilunar valve (SLV) regurgitation in the setting of a single ventricle physiology may proceed to valve replacement if repair strategies fail. Outcome data for these children are limited. We present transplant-free survival of a case series of children with single ventricle physiology undergoing either atrioventricular replacement (AVVR) or semilunar valve replacement (SLVR) from a multi-institutional, US-based registry (Pediatric Cardiac Care Consortium-PCCC). Outcomes were derived from PCCC and by linkage with the National Death Index (NDI) and Organ Procurement Transplant Network (OPTN). Fifty children with single ventricle physiology were identified to have received either AVVR (n = 38) or SLVR (n = 12). There were 17 in-hospital deaths including 8 intraoperative deaths (all intraoperative deaths were among children requiring AVVR). The in-hospital mortality was 42% and 8% for AVVR and SLVR, respectively. Among the 33 children surviving to hospital discharge, follow-up was available in 15 (46%). Death or cardiac transplant after hospital discharge occurred in 10-death in 4 (all among those requiring AVVR), cardiac transplant in 6 (2 following AVVR, 4 following SLVR). Valve replacement in children with single ventricle physiology, especially AVVR, is associated with poor outcomes. Alternative palliation strategies should be considered in children with single ventricle physiology with significant AVV or SLV regurgitations.

National Practice Patterns and Early Outcomes of Aortic Valve Replacement in Children and Teens

Several options exist for aortic valve replacement (AVR) in children and teens, but contemporary practice patterns and outcome data are lacking. We describe national AVR practice patterns and early outcomes. Children (aged 1 to 18 years) in The Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing AVR from 2000 to 2016 were included. Preoperative characteristics, operative data, and outcomes were described. To evaluate practice patterns, centers were assigned tertiles by aortic valve surgical volume. Statistical comparisons included Mann-Whitney U statistic, Kruskal-Wallis, χ2 test, and gamma testing. In total, 3446 operations (46% children aged 1 to 12 years; 54% teens aged 12 to 18 years) were included. Preoperative risk factors were present in 23%, and 46% had a prior sternotomy. Valve utilization included autograft (64% child, 37% teen), mechanical (19% child, 35% teen), bioprosthetic (8% child, 20% teen), and homograft (9% child, 7% teen). Autografts were utilized more often for teenage girls than for teenage boys (odds ratio 1.3, 95% confidence interval: 1.05 to 1.66, P < .05). Overall, inpatient mortality and major complications affected 1% and 10%, respectively, and these rates were highest for homografts (5%, P < .001, and 13%, P < .05). Autograft utilization varied widely across centers (10th to 90th percentile: 21% to 71% of total AVR volume). More autografts were utilized at high-volume centers vs low- or medium-volume centers (53% ± 2.3% vs 46% ± 2.6%, P < .001). Practice patterns for AVR in children and teens vary across centers, age groups, and sexes. Although early outcomes were similar across valve types, homografts had higher morbidity and mortality. Valve choice was related to aortic valve surgical volume. Further efforts are needed to understand and optimize AVR practice patterns and long-term outcomes.

GH and IGF-1 Replacement in Children.

In this chapter, we want to give an overview on what we have learned from more than 30 years ago on the use of recombinant human growth hormone (rhGH) and later recombinant human IGF-1 which was introduced for the treatment of short children and what are the safety issues concerned with this treatment. However, rhGH is used not solely in conditions where short stature is the consequence of GH deficiency but also in various disorders without a proven GH deficiency. In clinical studies, growth responses to various forms of rhGH therapy were analyzed, adding to our concept about the physiology of growth. Most patients under rhGH treatment show a considerable short-term effect; however, the long-term gain of height in a child obtained by a year-long treatment until final height remains controversial in some of the growth disorders that have been treated with rhGH or IGF-1. Today the first studies on the long-term safety of rhGH treatment have been published and raising some questions whether this treatment is similarly safe for all the patient groups treated with rhGH. Although there is a long-standing safety record for these hormone replacement therapies, in the face of the considerable costs involved, the discussion about the risk to benefit ratio is continuing. Newer developments of rhGH treatment include long-term preparations, which have only to be injected once a week. Although some of these drugs already have proven their non-inferiority to conventional rhGH treatment, we have to await further results to see whether they show improvements in treatment adherence of the patients and prove their long-term safety.

Outcomes of Mechanical Mitral Valve Replacement in Children

Mitral valve anomalies in children are rare but frequently severe, recalcitrant, and not often amenable to primary repair, necessitating mechanical mitral valve replacement (M-MVR). This study examined outcomes of a cohort undergoing a first M-MVR at age younger than 21 years. We queried the Pediatric Cardiac Care Consortium, a multi-institutional United States-based cardiac intervention registry, for patients undergoing first M-MVR for 2-ventricle congenital heart disease. Survival and transplant status through 2014 were obtained from Pediatric Cardiac Care Consortium and linkage with the National Death Index and the Organ Procurement and Transplantation Network. We identified 441 patients (median age, 4.3 years; interquartile range, 1.3 to 10.1 years) meeting study criteria. The commonest disease necessitating M-MVR was atrioventricular canal (44.3%). Early mortality (death <90 days after M-MVR) was 11.1%; there was increased risk of early death if age at M-MVR was younger than 2 years (odds ratio, 7.8; 95% confidence interval [CI], 1.1 to 56.6) and with concurrent other mechanical valve placement (odds ratio, 8.5; 95% CI, 2.0 to 35.6). In those surviving more than 90 days after M-MVR, transplant-free survival was 76% at 20 years of follow-up (median follow-up, 16.6 years; interquartile range, 11.9 to 21.3 years). Adjusted analysis in those who survived more than 90 days showed elevated risk of death/transplant for boys (hazard ratio, 1.5; 95% CI, 1.0 to 2.3), age at M-MVR younger than 2 years (10-year survival: hazard ratio, 4.3; 95% CI, 1.2 to 15.1), and nonbileaflet prosthesis placement (hazard ratio, 2.4; 95%CI, 1.3 to 4.3). M-MVR is a viable strategy in children with unrepairable mitral valve disease. Age younger than 2 years at the first M-MVR is associated with significant early risk of death and poorer long-term survival.

Fluid Replacement in Children with Dengue and Factors Associated with Pulmonary Edema

Fluid Replacement in Children with Dengue and Factors Associated with Pulmonary Edema

Reply - Fluid Replacement in Children with Dengue and Factors Associated with Pulmonary Edema: A Letter to Editor

Reply - Fluid Replacement in Children with Dengue and Factors Associated with Pulmonary Edema: A Letter to Editor