Mitral valve replacement in patients younger than 6 years of age

We present our experience in mitral valve replacement (including left-sided tricuspid valve in corrected transposition) in patients younger than 6 years of age. The long term results were examined with special focus on re-replacement of the valve. Between 1974 and 1995, we performed mitral valve replacement in 14 patients younger than 6 years of age, with no operative mortality. There were 3 late deaths, caused by endocarditis, valve thrombosis, and congestive heart failure, respectively. The five-year-survival rate after primary replacement was 85%, and the ten-year-survival rate was 75%, using Kaplan-Meier analysis. Ten patients (11 occasions) required repeated mitral valve replacements at 2 months to 17 years after the original replacement. The indication for the second or third mitral valve replacement was paravalvular leakage (2 patients), valve thrombosis (1 patient), degeneration in the porcine prosthesis (3 patients), and patient outgrowth of the original small prosthesis (5 patients). Again there was no operative mortality. One patient who suffered from multiple occasions of valve thrombosis died at two years after the second replacement. All patients who had outgrown the prosthetic valve received larger prosthesis at the second replacement than at the primary replacement. The actuarial percentage of freedom from valve-related events at 3 years, 5 years, and at 10 years, was 50%, 37%, and 8%, respectively. Conclusions: Mitral valve replacement in patients younger than 6 years of age can be performed relatively safely, but meticulous follow-up and appropriate decision making for re-replacement is mandatory for the long-term survival of these patients.     

Mitral valve replacement in children under 3 years of age.

OBJECTIVE: This study was undertaken to review our experience of mitral valve replacement in children under 3 years of age. METHODS: Between January 1990 and May 2004, 18 patients under 3 years of age underwent a total of 20 mitral valve replacements using a bileaflet mechanical prosthetic valve. There were 9 males and 11 females. The age at surgery ranged from 3 months to 3 (mean=1.02 +/- 0.72) years and body weight varied between 3.4 and 13.2 (mean=7.08 +/- 2.74) kg. RESULTS: There were 4 early and 2 late deaths, and these occurred in severe cases aged less than 1 year of age. Re-replacement of mitral valve was required in 3 patients (valve thrombosis in 2 and pannus formation in 1). Orifice size of the implanted prosthesis (OS) as compared with the predicted normal size of the mitral valve (NS) was well correlated with maximum transprosthetic flow velocity estimated by Doppler echocardiography. In this study, the OS/NS>0.65 was maintained in all patients, and none required re-replacement because of prosthesis-patient mismatch. CONCLUSION: Patients less than 1 year of age had significant mortality and morbidity. The results were satisfactory in the remainder (1-3 years). During this follow-up period, none required re-replacement due to somatic growth, but it will be an unavoidable problem in the future. The OS/NS, which can be checked with a regular physical examination, may serve as a guide to determine the most appropriate timing for the second surgery.     

Valve replacement in children under twenty years of age. Experience with the Bj?rk-Shiley prosthesis

Prosthetic valve replacement in young patients has been reported to be associated with a high mortality and morbidity because of valve-related problems. Of 549 patients undergoing valve replacement with the Bj?rk-Shiley valve prosthesis, 136 were under the age of 20 years. Sixty-four patients were under 16 years of age, the youngest being 6 years old. Of the 136 patients, 61 underwent mitral valve replacement, 50 received an aortic valve, and 25 received both aortic and mitral valves. Overall operative mortality was 10.3%. Late mortality over a follow-up period of 6 months to 8 years was 4.4%. Actuarial survival curves up to 8 years of follow-up are presented. Results obtained in this group are compared with those obtained in 413 patients over 20 years of age operated during the same period. Valve thrombosis was not seen in any patient under 20 years of age, but it occurred in 4.13% of the patients over 20 years of age. The incidence of thromboembolism and anticoagulant-related hemorrhage was very low. There has been no instance of structural failure of the valve. Long-term results are excellent, with 90% of the survivors returning to New York Heart Association Functional Class I. The Bj?rk-Shiley valve gives excellent and durable long-term palliation in young patients requiring valve replacement.     

Mitral valve replacement for children with a small annulus using ATS open pivot prosthesis

Objectives: The present study was conducted to review our experience of mitral valve replacement (MVR) in small children with the ATS open pivot prosthesis.Methods: Between January 1999 and March 2002, 14 patients (7 males and 7 females) underwent a total of 15 ATS MVRs; 16AP in 9, 18AP in 3, and 20AP in 3 occasions. The mean age and body weight at operation were 1.1±0.7 (range 0.2 to 2.7) years and 6.8 ±2.6 (range 2.8 to 12.5) kg, respectively.Results: There were 2 early and 2 late deaths, each non-valve related. Excluding one patient, the orifice size of the prosthesis was larger than the predicted normal size of the mitral valve for the age. The postoperative Doppler echocardiogram demonstrated normal maximal flow velocity across the prosthesis. There was no morbidity among survivors except for the patient who developed a stuck and immobile valve disc 10.2 months after the operation and required re-replacement.Conclusions: Our experience shows that MVR with the ATS open pivot prosthesis is a promising surgical option for small children.     

Late results after mitral valve replacement with bileaflet mechanical prosthesis in children: evaluation of prosthesis-patient mismatch

BACKGROUND: Mechanical prosthesis is the choice of valve at the mitral position in children, although re-replacement of prostheses because of prosthesis-patient mismatch is almost inevitable when prostheses were implanted in small children. The methods to predict prosthesis-patient mismatch as a result of patients' somatic growth or pannus formation in children by noninvasive methods have not been well established. METHODS: Thirty-two children underwent mitral valve replacement with 37 bileaflet mechanical prostheses (26 St. Jude Medical prosthetic valves, and 11 CarboMedics prosthetic valves) and were followed up a mean of 6.8 years (maximum 18.3 years) with a complete follow-up rate of 94%. RESULTS: There were no operative deaths and 5 late deaths. Re-replacement of mitral valve because of prosthesis-patient mismatch was required in 5 patients. Freedom from valve-related events and re-replacement of mitral valve at 15 years were 32% +/- 23% and 54% +/- 18%, respectively. Actuarial survival rate was 63% +/- 19% at 15 years. Prosthetic valve orifice area index (manufactured geometric prosthetic valve area divided by patient's body surface area) was well correlated with maximum transprosthesis flow velocity estimated by Doppler echocardiography during follow-up, whereas valve orifice area index had no significant correlation with pulmonary artery wedge pressure assessed by cardiac catheterization. Maximum transprosthesis flow velocity had a significant correlation with pulmonary artery wedge pressure. CONCLUSIONS: Valve orifice area index itself was not a reliable index to predict prosthesis-patient mismatch. Maximum transprosthesis flow velocity was a useful index to predict pulmonary artery wedge. Invasive cardiac catheterization to determine re-replacement of the prosthesis should be considered when maximum transprosthesis flow velocity exceeds 270 cm/s.     

Mitral valve replacement in children under 3 years of age

Objective: This study was undertaken to review our experience of mitral valve replacement in children under 3 years of age. Methods: Between January 1990 and May 2004,18 patients under 3 years of age underwent a total of 20 mitral valve replacements using a bileaflet mechanical prosthetic valve. There were 9 males and 11 females. The age at surgery ranged from 3 months to 3 (mean=1.02±0.72) years and body weight varied between 3.4 and 13.2 (mean=7.08±2.74) kg. Results: There were 4 early and 2 late deaths, and these occurred in severe cases aged less than 1 year of age. Re-replacement of mitral valve was required in 3 patients (valve thrombosis in 2 and pannnus formation in 1). Orifice size of the implanted prosthesis (OS) as compared with the predicted normal size of the mitral valve (NS) was well correlated with maximum transprosthetic flow velocity estimated by Doppler echocardiography. In this study, the OS/NS>0.65 was maintained in all patients, and none required re-replacement because of prosthesis-patient mismatch. Conclusion: Patients less than 1 year of age had significant mortality and morbidity. The results were satisfactory in the remainder (1–3 years). During this follow-up period, none required re-replacement due to somatic growth, but it will be an unavoidable problem in the future. The OS/NS, which can be checked with a regular physical examination, may serve as a guide to determine the most appropriate timing for the second surgery.     

Valve replacement in children

Between May 1979 and September 1998, 202 children underwent surgical treatment for valvular heart disease. Of these 23, who ranged in age from 25 days to 15 years, underwent valve replacement, including 1 reoperation. The valve replacement consisted of the aortic valve in 5 patients, the mitral valve in 3, the tricuspid valves in 9, including 5 systemic atrioventricular valves for atrioventricular discordance, the pulmonary valve in 6, 5 bioprostheses and 18 mechanical prostheses. There were 4 operative deaths, 1 hospital death and 3 late deaths. At the 10-years follow-up, the actual survival rate was 67.8%, the event free rate was 76.1% and the freedom from reoperation rate was 86.2%. Valve re-replacement was performed in only 1 patient due to a thrombosed tricuspid valve. These results suggest that there is a small risk of major complications and reoperation in children who undergo valve replacement, whether a bioprosthetic valve or a mechanical valve. The long-term results of younger patients should be followed more closely according to their growth.     

Intermediate-term results after the aortic valve replacement using bileaflet mechanical prosthetic valve in children.

OBJECTIVE: Intermediate/long-term results after aortic valve replacement using bileaflet mechanical valve in children should be clarified as a standard of treatment of aortic valve disease in children. METHODS: Forty-five patients aged under 15 years underwent 46 aortic valve replacements using bileaflet mechanical prosthetic valve. Patients' ages ranged from 1 to 15 years (9 years as a median value), and follow-up period was 9.2 years as a median value (maximum 19 years). RESULTS: In situ valve replacement was performed in 21 procedures, while annular enlargement was required in 25 procedures (Nicks 10, Yamaguchi 3, Manouguian 2, Konno 10). All patients except two received prosthesis 19mm or larger in size. There was one operative death and two late deaths. Two episodes of cerebral infarction, two valve thrombosis, two re-operations, one infective endocarditis, and one sudden death were recognized as valve-related complications in five patients. The reasons for re-operation were prosthesis-patient mismatch in one (Ross procedure) and valve thrombosis in one (re-replacement). At 15 years after the operation, re-replacement free rate, valve-related event free rate and actuarial survival rate were 94+/-4%, 86+/-6% and 92+/-4%, respectively. The transprosthetic flow velocity estimated by Doppler echocardiography at the final follow-up was well correlated with manufactured valve area index (cm(2)/body surface area). CONCLUSIONS: Although aortic annular enlargement was required in more than half of the cases, intermediate-term results after aortic valve replacement using bileaflet mechanical prosthetic valve in children was satisfactory. Indications for alternative treatment such as Ross procedure might be considered in limited cases.     

Long-term follow-up after mitral valve replacement in childhood: poor event-free survival in the young child.

OBJECTIVE: In children, mechanical mitral valve replacement may be the only option if the failing mitral valve cannot be repaired. Mandatory anticoagulation and the fixed size prosthesis are of concern in the growing child, but long-term follow-up results are lacking. METHODS: Single centre, extended retrospective study of 54 patients who underwent first mitral valve replacement between June 1982 and December 1997. Median age at operation was 3.0 years (range 2 days-18.1 years), 21 patients were15 years (maximum 22 years) in nine patients. RESULTS: Thirty-day mortality was 42% in patients相似文献   

Acute mechanical valve thrombosis of the St. Jude medical prosthesis

From 1986 to 1996, 2585 patients underwent valve replacement with the St. Jude medical prosthesis. Sixty experienced mechanical valve thrombosis. Seventeen of 60 patients (28.3%) had isolated aortic valve replacements, 33 had isolated mitral valve replacements (55%), and 10 had double valve replacements (16.7%) (aortic and mitral valve replacement). All patients who underwent reoperation for mechanical valve thrombosis were functional Class III or IV. Against medical advice, systemic anticoagulation with warfarin sodium had been discontinued or used only intermittently. Thus, anticoagulant activity was not adequate. The diagnosis of thrombosis was made by clinical examination, laboratory findings, and echocardiography and cineradiography. Of the 60 patients, 9 patients died early after surgery or before discharge. Most of the deaths were attributed to low cardiac output. The overall hospital mortality was 15%. The overall 10-year actuarial survival rate was 82.8+/-1.6%. In our study, reoperation for thrombosed mechanical prosthesis was not an independent parameter determining mortality. Age was the only statistically important hospital mortality predictor. Of this group, 90% suffered mechanical valve obstruction within the first 5 years after operation. These results suggest that valve re-replacement appears to be a suitable surgical treatment for thrombosis of mechanical prosthetic valves, especially in the young. In these patients subsequent anticoagulation management is necessary.     

Three-year clinical results with the Monostrut Bj?rk-Shiley prosthesis

Between November 1981 and June 1983, 351 patients underwent valve replacement with the Monostrut Bj?rk-Shiley prosthesis. There were 214 aortic valve replacements, 101 mitral valve replacements, and 31 double (aortic and mitral) valve replacements. Four patients had valve implanted in the tricuspid position, and one patient underwent exchange of a valved, extracardiac conduit. Mean age was 61 years (range 2 to 78) and 186 (53%) were male. Concomitant procedures were performed in 52 patients (15%) and 17 (5%) were emergency operations. Early mortality (4.3%) was related to New York Heart Association Functional Class IV, emergency operation, or the presence of a concomitant procedure. Follow-up was 100% and covered 870 patients-years (mean 2.6 years per operative survivor). Postmortem examination was performed in 38 (79%) of the 48 fatalities. Only one patient suffered a sudden, unexplained death. The 3 year survival rate (early mortality excluded) was 88.6% (aortic valve replacement 89.2%, mitral valve replacement 89.3%, and double valve replacement 82.5%). The 3 year freedom from thromboembolism in patients receiving anticoagulants was as follows: aortic valve replacement 97.5%, mitral valve replacement 92.8%, and double valve replacement 100%. There were no instances of valve thrombosis or fatal embolism. In contrast, there were two instances of aortic valve thrombosis among 34 patients having aortic valve replacement without anticoagulation. The 3 year freedom from valve failure (modified Stanford definition) was as follows: aortic valve replacement 96.0%, mitral valve replacement 93.9%, and double valve replacement 89.7%. There were no mechanical failures. In conclusion, the Monostrut Bj?rk-Shiley valve showed a low incidence of complications. There were no mechanical failures, no fatal emboli, and, when anticoagulants were administered, no valve thromboses.     

Fourteen years' experience with the Bj?rk-Shiley tilting disc prosthesis

Between 1970 and 1984, 1,574 Bj?rk-Shiley valve prostheses have been implanted in 1,171 patients in Glasgow. Between 1970 and 1980, 1,023 standard disc prostheses were implanted in 729 patients: 184 had aortic valve replacement, 323 mitral, and 222 multiple valve replacement. Between 1980 and 1984, 551 convexo-concave valves were implanted in 442 patients: 125 had aortic, 228 mitral, and 89 multiple valve replacement. Concomitant coronary artery bypass grafting was performed in 9.2% of the latter group as compared with 2.7% of the earlier group. The overall hospital (30 day) mortality for the group with the standard disc prosthesis was 10.4% and for patients with the convexo-concave prosthesis, 7.0%. Cumulative follow-up extends to 4,125 patient-years--standard disc group 3,378 patients-years, range 4 to 14 years (mean 5.2 years); convexo-concave group 747 patient-years, range 1.5 to 5.3 years (mean 1.9 years). The late mortality is 3.8% per patient-year--standard disc group 2.9% per patient-year and convexo-concave group 4.3% per patient year (no significant difference). Actuarial survival rate at 12 years for the whole group, excluding operative deaths, is 69.4% +/- 6.3%. The freedom from all valve-related complications at 12 years is 65.9% +/- 6.5%. there is no significant difference in the incidence of most major complications between the standard disc and convexo-concave prostheses apart from the occurrence of mitral valve thrombosis (p less than 0.05) in the standard disc group and outlet strut fracture (p less than 0.005) in the convexo-concave group. These results confirm the excellent long-term performance of the Bj?rk-Shiley tilting disc prosthesis.     

Replacement of the aortic valve in patients under 50 years of age: long-term follow-up of the St. Jude Medical prosthesis

BACKGROUND: Aortic valve replacement in the young adult (aged 18 to 50 years) is a choice between a mechanical prosthesis with attendant lifelong anticoagulation or biological prostheses of varying types that may have limited life expectancy in this age group. METHODS: The Cardiac Surgical Research Foundation database was accessed to determine long-term outcomes in patients having aortic valve replacement with the St. Jude Medical Valve. This database has been privately maintained since the world's first St. Jude Medical (SJM) valve implant in 1977. Patients were contacted by questionnaire or by telephone if the survey was not returned. Follow-up was 93% complete. RESULTS: From October 1977 through October 1997, 271 patients less than 50 years of age had isolated aortic valve replacement. Follow-up was 1957 patient years. Thirty-day operative mortality was 1.1% with 18 late deaths, 4 of which were valve related. Ninety percent of survivor INR responses indicated a frequency of monthly INR checks or less. Valve-related events including percent per patient year and mortality related to these events included thromboembolism, 6 episodes (0.3% per patient year, no deaths); anticoagulant-related bleeding, 6 events (0.3% per patient year, 2 deaths); paravalvular leak, 6 events (0.3% per patient year, 2 deaths); valve thrombosis, 2 events (0.1% per patient year, no deaths); and endocarditis, 3 events (0.15% per patient year, no deaths). There was no incidence of structural valve failure. CONCLUSIONS: The SJM valve has a long record of excellent performance with durability lasting more than 20 years. The incidence of untoward events is low and death over time due to valve-related complications is low (4 of 271). The SJM valve has become our valve of choice for younger patients.     

Mitral valve replacement using bileaflet mechanical prosthetic valve in the first year of life.

OBJECTIVE: The operative management and long term outcome of mitral valve replacement in infancy remain a therapeutic challenge. The selection of a prosthetic valve for this particular age group might affect the clinical outcome. Here we present our experience of mitral valve replacement in 6 infants using small bileaflet mechanical prosthetic valves. METHODS: Between January 1994 and August 1997, 6 infants (their age ranged from 3 months to 11 months, and their body weight from 2978 g to 7403 g) underwent mitral valve replacement using a mechanical valve prosthesis (16 mm CarboMedics prosthetic valve in 5, and 17 mm St. Jude Medical prosthetic valve Hemodynamic Plus in 1). The preoperative morphological features of the mitral valve were stenosis in 1, regurgitation in 3, and a combination of these in 2. The prosthesis was fixed at the annulus in 3, and at the supra-annular position in 3. Anticoagulation was performed using warfarin. RESULTS: There was no operative mortality. Postoperative catheterization revealed an acceptable wedge pressure in the pulmonary arteries, ranging from 10 to 12 mmHg. During the mean follow-up period of 36 months, late death due to residual pulmonary hypertension occurred in 1 patient at 10 months after surgery. Excluding this patient, all remaining patients are doing well with no need for repeated operation with no thromboembolic complication. The actuarial survival rate and the reoperation free rate at 70 months are 83 +/- 15% and 100%, respectively. CONCLUSION: Mitral valve replacement using a small size bileaflet mechanical prosthetic valves in infancy can be performed with low operative mortality and with satisfactory mid-term results.     

Thirteen years evaluation of the Bjork-Shiley isolated mitral valve prosthesis. The Wessex experience

Between 1973 and 1985, 349 patients had isolated mitral valve replacement by a Bjork-Shiley prosthesis with an overall early (30 day) mortality of 5.1%. Of the 331 survivors, 294 patients have been traced and their clinical outcome was followed for up to 13 years in order to define the long term performance of the mitral Bjork-Shiley models MBRP-standard, MBRC-convexo concave and MMSM-monostrut. Cumulative follow-up extends to 6620 patient years (mean 5.75 years). The MBRP valve was implanted in 236 patients, the MBRC valve used in 44 patients and the MMSM valve inserted in 14 patients. The late mortality and morbidity was 0.8% and 0.6% per patient year at 13 years respectively. Actuarial survival rate for the whole group excluding operative deaths was 85% at 5 years, 66% at 10 years and 58.5% at 13 years. The freedom from all valve related complications at 13 years was 70.75%. Bjork-Shiley models MBRP, MBRC and MMSM mitral valve prosthesis show excellent durability with only one case of mechanical failure over a 13 year period.     

The Bj?rk-Shiley tilting disc valve in the tricuspid position. 10-year experience

Ten-year experience of tricuspid valve replacement with the Bj?rk-Shiley pyrolytic carbon disc is reported. Of the twelve patients, one died in association with the operation, due to tracheo-oesophageal fistula. There were four late deaths, two from unknown causes, one during re-replacement of mitral valve and one from carcinoma of the urinary bladder. No patient had thromboembolism, valve thrombosis or subacute infective endocarditis. From the analysis of the hospital records and follow-up data it is concluded that the Bj?rk-Shiley pyrolytic carbon disc prosthesis is a satisfactory substitute for the tricuspid valve.     

儿童心瓣膜病的外科治疗

目的 报告儿童心瓣膜手术的经验。方法 ８７儿童心瓣膜病变患者,男５８例,女２９例,年龄４～１４岁,平均年龄１０．２岁。其中二尖瓣置换术３６例,主动脉置换术１３例,二尖瓣和主动脉瓣双瓣膜置换术６例,主动脉瓣成形术１３例,二尖瓣成形术１９例,所用心瓣膜均为机械瓣。同期处理三尖瓣关闭不全４１全,室间隔缺损２３例,房间隔缺损９例,佛氏窦瘤破裂８例,动脉导管未闭３例。结果 术后早期并发症包括：低心排血量综合     

Long-term results after Starr-Edwards mitral valve replacement in children aged 5 years or younger

BACKGROUND: Mitral valve replacement with prosthetic valves in infants and children requires consideration of multiple variables. When we examined our late follow-up, the effect of the growth of the patient relative to the size of the prosthesis placed was the most important variable predicting late successful results. We reviewed our experience with mitral valve replacement using the Starr-Edwards ball valve in children aged 5 years or younger, focusing on the effect of valve prosthesis-patient mismatch on the long-term results in the growing patient. METHODS: From August 1974 to June 1986, 8 patients aged 5 years or younger underwent mitral valve replacements using the Starr-Edwards prosthesis size OM in 3 patients and 1M in 5 patients. Model 6320 was used in 1 patient and Model 6120 in the remaining 7 patients. RESULTS: Follow-up was 100% from 15 to 27 years (mean, 20 years). No valve-related complications of thromboembolism, anticoagulant-related hemorrhage, or prosthetic valve endocarditis were seen. All patients normally developed to adult size. The range of the valve area index of the 3 patients who received the smaller Starr-Edwards valve (size OM) was 0.97 to 1.24 cm2/m2. Although this size valve was adequate for patient growth to adolescence, in each case valve replacement with a larger valve was required. CONCLUSIONS: Our long-term review of Starr-Edwards ball valve mitral valve replacement in children aged 5 years or younger shows that the Starr-Edwards ball valve (Models 6320 [1 patient] and 6120 [7 patients]) showed excellent durability, no thromboembolism, and no anticoagulant-related complications. Size OM valves required replacement for hemodynamic reasons because of patient growth; larger size 1M valves remained hemodynamically satisfactory in spite of patient growth.     

Mechanical valve thrombosis in the tricuspid position--reoperative management of 2 cases

Because valve thrombosis occurred after the tricuspid valve replacement with the mechanical valve, we performed replacement of the mechanical valve with the bovine pericardial valve in two cases. Case 1: The patient, at 13 years old, received open-heart surgery to correct infundibular stenosis. At 23 years of age, decortication and tricuspid valve replacement (TVR) with a phi 31 mm Bj?rk-Shiley valve were performed due to constrictive pericarditis and tricuspid regurgitation developed after the initial operation. Thrombosis of the mechanical valve occurred after the TVR. Treatment with urokinase for the thrombolytic therapy failed to improve the valve opening. Finally 12 years after the TVR, replacement of the mechanical valve with a phi 27 mm Carpentier-Edwards bovine pericardial valve was performed. Case 2: The patient, at 21 years old, received open-heart surgery to close an atrial septal defect. At 40 years of age, mitral and tricuspid valve replacements were performed because regurgitation developed in both valves. The mitral and tricuspid valves were replaced with phi 27 mm and 31 mm St. Jude Medical valves, respectively. Thrombosis of the mechanical valve used for the TVR occurred 2 months after the replacement. The mechanical valve was replaced with a phi 27 mm Carpentier-Edwards bovine pericardial valve. In both cases, subjective symptoms improved and prosthetic valve complications did not occur after re-replacement with the bovine pericardial valve. These cases suggested that for TVR a bovine pericardial valve of sufficient size would be better to select than a mechanical valve.     

Mitral valve replacement in the first 5 years of life

Between 1976 and 1986, 19 children aged 1 month to 5 years underwent replacement of the mitral (systemic atrioventricular) valve. Indications for valve replacement included isolated congenital mitral stenosis (n = 2), valve dysfunction associated with a more complex procedure (n = 15), and failed valvuloplasty (n = 2). Seven different valve types were used; nine were mechanical valves and ten were bioprosthetic valves. There were 6 hospital deaths (32%; 70% confidence limits, 20% to 47%). Among the 13 survivors there were 3 late deaths at a mean of 14 months after operation. The late deaths were unrelated to valve malfunction. Thromboembolic events occurred in 2 patients, both with mechanical valves. One minor bleeding complication occurred among 10 patients on a regimen of Coumadin (crystalline warfarin sodium). Five patients, all with bioprostheses, required a second valve replacement. Indications for reoperation included prosthetic valve regurgitation (n = 1) and calcific stenosis (n = 4). No early or late deaths occurred after second valve replacement. Survival was 51% +/- 12% (standard error) at 112 months after valve replacement. Analysis failed to identify age, weight, sex, previous operation, underlying cardiac lesion, or prosthesis size and type as significant risk factors for mortality. Mechanical valves had a lower reoperation rate compared with bioprostheses. These data suggest that although mitral valve replacement within the first 5 years of life is associated with a high operative and late mortality, satisfactory long-term palliation for many patients can be achieved. Mechanical valves are superior to bioprosthetic valves, and offer the best long-term results.