Evolution of mitral valve replacement in children: A 40-year experience

John W. Brown, Andrew C. Fiore, Mark Ruzmetov, Osama Eltayeb, Mark D. Rodefeld, Mark W. Turrentine

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Abstract

Background: This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors. Methods: 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. Results: 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). Conclusions: 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.

Original languageEnglish (US)
Pages (from-to)626-633
Number of pages8
JournalAnnals of Thoracic Surgery
Volume93
Issue number2
DOIs
StatePublished - Feb 2012

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Mitral Valve
Reoperation
Heterografts
Mortality
Pediatrics
Autografts
Heart Transplantation
Hospital Mortality
Endocarditis
Embolism
Prostheses and Implants
Allografts
Pathologic Constriction
Thrombosis
Swine
Hemorrhage
Morbidity
Weights and Measures
Lung
Survival

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Evolution of mitral valve replacement in children : A 40-year experience. / Brown, John W.; Fiore, Andrew C.; Ruzmetov, Mark; Eltayeb, Osama; Rodefeld, Mark D.; Turrentine, Mark W.

In: Annals of Thoracic Surgery, Vol. 93, No. 2, 02.2012, p. 626-633.

Research output: Contribution to journalArticle

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abstract = "Background: This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors. Methods: 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. Results: 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). Conclusions: 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.",
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T2 - A 40-year experience

AU - Brown, John W.

AU - Fiore, Andrew C.

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AU - Rodefeld, Mark D.

AU - Turrentine, Mark W.

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N2 - Background: This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors. Methods: 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. Results: 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). Conclusions: 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.

AB - Background: This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors. Methods: 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. Results: 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). Conclusions: 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.

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