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

Abstract

Objective: To identify risk factors for pediatric mechanical mitral valve replacement (mMVR) to improve management in this challenging population. Methods: 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]. Results: 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%. Conclusion: 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.

National In-Hospital Outcomes of Mechanical Mitral Valve Replacement in the Pediatric Population

“…The Mayo Clinic experience has shown a temporal decrease in early mortality with time in patients <2 years (14% [1993][1994][1995][1996][1997][1998][1999][2000], 9% [2001][2002][2003][2004][2005][2006][2007][2008][2009][2010], and 0% in 2011-2019]); however, this study was limited by a relatively small sample size in this younger age group. 14 The authors attributed the improved outcomes in the last decade to early intervention, improved surgical experience, improvement in perioperative care, and implementation of updated anticoagulation protocols. The 15-mm m-MVR from St Jude Medical was approved recently by the US Food and Drug Administration and has been utilized as the smallest available m-MVR.…”

“…Historically, younger age at time of surgery was a major risk factor for in-hospital morbidity and mortality in comparison to older children and adolescents; early mortality in children <2 years was reported between 11% and 42% in small observational studies. 2,9,14,15 A recent large multicenter study by Ibezim and associates found that early mortality in patients <2 years was as high as 25% (36/144 patients). 8 In-hospital mortality in our investigation in neonates and infants was 11% (11/96 patients) demonstrating improved early mortality in the most recent era.…”

“…The Mayo Clinic experience has shown a temporal decrease in early mortality with time in patients <2 years (14% [1993-2000], 9% [2001-2010], and 0% in 2011-2019]); however, this study was limited by a relatively small sample size in this younger age group. 14 The authors attributed the improved outcomes in the last decade to early intervention, improved surgical experience, improvement in perioperative care, and implementation of updated anticoagulation protocols.…”

“…The overall in-hospital mortality was 4.8% and was significantly higher in neonates and infants (10% vs 11.8% vs 3.2%, P = .003, Table 3). Figure 1 shows the timing of mortality during hospital 10 days [7][8][9][10][11][12][13][14][15][16][17][18] in older children and adolescents, P < .01).…”

World Journal for Pediatric and Congenital Heart Surgery—The Official Journal of the Congenital Heart Surgeons’ Society

“…As has been true from the outset, CHSS and ECHSA membership and leadership (past and present) make up a sizeable portion of the WJPCHS' Editorial Board. CHSS and ECHSA presidential addresses have been published in WJPCHS, 4,5 as have numerous papers presented at annual meetings [6][7][8][9] and cohort analyses from the Data Centers of both Societies. [10][11][12][13][14][15][16] Both the past and present Editors-in-Chief are past presidents of the CHSS.…”