Outcomes of Mechanical Mitral Valve Replacement in Children

Abstract

Background. 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. Methods. 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. Results. 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). Conclusions. 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.

Management of the bad atrioventricular valve in Fontan…time for a change

“…28 Studies of mitral valve replacement in children with a biventricular circulation have also demonstrated poor results, with early mortality rates that range from 10% to 20%. 29,30 Alsoufi and colleagues 30 examined outcome in a very young group of 79 patients (median age 24 months) and on competing risk analysis at 10 years, mortality was 40% without repeat mitral valve replacement, 20% with repeat mitral valve replacement, and 40% were alive without need for reoperation. In the recent Pediatric Cardiac Care Consortium study that examined a large number of children (n ¼ 441; median age 4.3 years), transplant-free survival at 20 years was 76%.…”

“…In the recent Pediatric Cardiac Care Consortium study that examined a large number of children (n ¼ 441; median age 4.3 years), transplant-free survival at 20 years was 76%. 29…”

“…Although mechanical valve replacement and the concomitant need for warfarin anticoagulation are not an ideal alternative, 29,30 the dismal results documented with a ''bad atrioventricular valve, bad Fontan circulation'' is precisely the reason it should be considered more seriously.hence, a different mindset to address this problem.…”

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

“…[2] Because of early calci cation and short durability of bioprostheses, mechanical mitral valve replacement (M-MVR) is the most common choice for the pediatric population, especially for neonates and infants [3]. In these cases, a larger-sized prosthesis valve is implanted into the small annulus, possibly causing high mortality, left ventricular out ow obstruction (LVOTO), complete atrioventricular block postoperatively, pulmonary vein stenosis, low valve durability and need for anticoagulant management postoperatively [4]. During the last century, many techniques and prosthesis have been employed to treat mitral valve diseases in infants and the outcomes of the MVR in the patients weighning 10 kg are not always favorable.To better understand the optimal approach to this complex problem, we retrospectively examined our experience with children less than 3 years old and weighing less than 10 kg who underwent M-MVR.…”

Long-Term Outcomes of Mitral Valve Replacement in Patients Weighing Less Than 10 Kg

“…[2] Because of early calci cation and short durability of bio-prostheses, mechanical mitral valve replacement (mMVR) is the most common choice for the pediatric population, especially for neonates and infants [3]. In these cases, a largersized prosthesis valve is implanted into the small annulus, possibly causing high mortality, left ventricular out ow obstruction (LVOTO), complete atrioventricular block postoperatively, pulmonary vein stenosis, low valve durability and need for anticoagulant management postoperatively [4]. During the past decades, many techniques and prosthesis have been employed to treat mitral valve diseases in infants and the outcomes of the MVR in the patients weighing 10 kg are not always favorable.To better understand the optimal approach to this complex problem, we retrospectively examined our experience with children less than 3 years old and weighing less than 10 kg who underwent mMVR.…”