Mitral valve replacement in children

Rheumatic fever leading to advanced valvular heart disease, in adults and children, is still frequently seen in developing countries. In the period 1981-87, 1137 patients underwent open heart surgery for either repair (489 patients), or replacement (639 patients) of defective cardiac valves. The experience with 75 children who underwent mitral valve replacement among this group is reviewed. The aetiology of mitral valve disease was rheumatic in 71, and infective endocarditis in four; 85% of the children were in NYHA functional class III, and 15% in class IV. Seven children had intra-operative findings of rheumatic activity. Pure mitral regurgitation was seen in 41, while mixed mitral valve disease was observed in 34 children. Twenty-seven children underwent mitral valve replacement with Ionescu-Shiley bovine pericardial valves, and 48 with mechanical Bi-leaflet valves. The operative mortality was 9.3%, and the actuarial survival rate, calculated by the Cutler and Ederers method, was 87% at 5 years.     

Early and late results of mitral valve repair for mitral valve regurgitation. Significant risk factors of reoperation

BACKGROUND: Mitral valve repair for mitral valve regurgitation has many advantages over mitral valve replacement. However, durability and reoperation after mitral valve repair still remain major problems. We examined the outcome of mitral valve repair for mitral valve regurgitation and analyzed several pre- and intraoperative potential risk factors to determine the significant risk factors of reoperation. METHODS: From February 1981 to November 1996, 86 patients underwent mitral valve repair for mitral regurgitation or combined mitral regurgitation and stenosis. The mean age was 53 years, and 88.4% were New York Heart Association class III or IV. The causes of mitral valve disease were degenerative disease in 53 patients, rheumatic disease in 15, infective endocarditis in 11, and ischemic disease in 7. There were 2 early and 8 late deaths. RESULTS: Actuarial overall survival including early death at 10 years was 83.2+/-6.1%, freedom from reoperation was 86.8+/-5.3%, freedom from thromboembolism was 90.9+/-6.2%, and freedom from infective endocarditis was 98.5+/-1.5%. There was no bleeding event. At the last follow-up, most patients were in New York Heart Association class I or II. Prolapse of anterior leaflet and rheumatic mitral regurgitation were identified as independent predictors for reoperation. CONCLUSIONS: The repair techniques for anterior leaflet prolapse and patient selection in rheumatic mitral disease are important for improving long-term results of mitral valve repair for mitral regurgitation.     

老年风湿性二尖瓣病变行二尖瓣修复术与生物瓣膜置换术中期效果比较

目的比较60岁以上老年患者风湿性二尖瓣修复(MVP)与生物瓣膜置换(MVR)的中期效果。方法选取2014年1月至2016年1月北京安贞医院瓣膜外科诊疗中心行风湿性二尖瓣修复或生物瓣置换手术的60岁以上老年风湿性二尖瓣病变患者,包括同期行三尖瓣修复术及房颤射频消融术患者;排除合并主动脉瓣手术、冠状动脉旁路移植手术、二次手术患者,最终纳入患者82例。根据二尖瓣手术方式分为二尖瓣修复组(MVP组,25例)和生物瓣置换组(MVR组,57例)。采用Kaplan-Meier法进行生存分析并绘制曲线,通过Log Rank方法比较两组患者5年生存率的差异。结果围手术期全组患者平均年龄(66.37±4.41)岁。54.9%的患者心功能(NYHA分级)Ⅲ级。两组患者在体外循环时间(P=0.99),主动脉阻断时间(P=0.88),术后住院时间(P=0.76)差异均无统计学意义。MVR组3例患者住院期间死亡,病死率5.3%;MVP组无住院期死亡(P=0.24)。随访5年,最长随访63个月,平均随访47.03个月。MVR组6例死亡,其中4例死于心脑血管不良事件,2例死于非心脑血管不良事件。MVP组无死亡。两组均无再手术病例。结论风湿性二尖瓣病变的老年患者采用二尖瓣修复手术治疗能够获得较好的中期效果。     

Mitral valve repair with aortic valve replacement is superior to double valve replacement

OBJECTIVES: Double valve replacement has been advocated for patients with combined aortic and mitral valve disease. This study investigated the alternative that, when feasible, mitral valve repair with aortic valve replacement is superior. Patients and Methods: From 1975 to 1998, 813 patients underwent aortic valve replacement with either mitral valve replacement (n = 518) or mitral valve repair (n = 295). Mitral valve disease was rheumatic in 71% and degenerative in 20%. Mitral valve replacement was more common in patients with severe mitral stenosis (P =.0009), atrial fibrillation (P =.0006), and in patients receiving a mechanical aortic prosthesis (P =.0002). These differences were used for propensity-matched multivariable comparisons. Follow-up extended reliably to 16 years, mean 6.9 +/- 5.9 years. RESULTS: Hospital mortality rate was 5.4% for mitral valve repair and 7.0% for replacement (P =.4). Survivals at 5, 10, and 15 years were 79%, 63%, and 46%, respectively, after mitral valve repair versus 72%, 52%, and 34%, respectively, after replacement (P =.01). Late survival was increased by mitral valve repair rather than replacement (P =.03) in all subsets of patients, including those with severe mitral valve stenosis. After repair of nonrheumatic mitral valves, 5-, 10-, and 15-year freedom from valve replacement was 91%, 88%, and 86%, respectively; in contrast, after repair of rheumatic valves, it was 97%, 89%, and 75% at these intervals. CONCLUSIONS: In patients with double valve disease, aortic valve replacement and mitral valve repair (1) are feasible in many, (2) improve late survival rates, and (3) are the preferred strategy when mitral valve repair is possible.     

Mitral valve repair and replacement for rheumatic disease

OBJECTIVES: Mitral valve repair may be technically feasible in patients with suitable anatomy, but the appropriateness of repair for rheumatic disease remains controversial. We evaluated our late outcomes after mitral repair and replacement for rheumatic disease. METHODS: Five hundred seventy-three patients underwent mitral valve surgery for rheumatic disease at our institution from 1978-1995. Follow-up was 98% complete (mean, 68 +/- 46 months). Survival and morbidity were evaluated by Kaplan-Meier analysis and Cox regression, including propensity score analysis. RESULTS: Mean age was 54 +/- 14 years, 55% of patients had congestive heart failure, 22% were undergoing redo mitral valve surgery, and 9% also underwent coronary bypass. Mitral stenosis was present in 53%, regurgitation in 15%, and both in 32%. Valve repair was performed in 25%, bioprosthetic replacement was performed in 28%, and a mechanical valve was placed in 47%. Patients undergoing repair were younger and less likely to be undergoing reoperation or to have atrial fibrillation than those undergoing replacement (P =.001). The operative mortality rate was 4. 2%. Better late cardiac survival was independently predicted by valve repair rather than replacement (P =.04) after adjustment for baseline differences between patients. Freedom from reoperation was greatest (P =.005) but that from thromboembolic complications was worst (P <.0001) after mechanical valve replacement. Twenty-three patients underwent reoperation after initial repair, with no operative deaths. CONCLUSIONS: Mechanical valves minimize reoperation but limit survival and increase thromboembolic complications. Patients undergoing valve repair had improved late cardiac survival independent of their preoperative characteristics. Rheumatic mitral valves should be repaired when technically feasible, accepting a risk of reoperation, to maximize survival and reduce morbidity.     

Midterm outcome of mitral valve repair for congenital mitral regurgitation in infants and children

We analyzed the midterm results of children undergoing mitral valve repair without the use of prosthetic materials focusing on mitral annulus growth. From 1991 to 2004, 17 children (median age: 11 months) underwent mitral valve repair (grade III=9, IV=8). Regurgitation was due to prolapsed leaflet in 8 patients, annular dilatation in 4, and restrictive leaflet motion in 5. Preoperative indexed mitral valve diameter and Z-value were compared with those obtained at follow-up. There were no early or late deaths. All patients had an improved regurgitation grade after surgery. MV repair resulted in reduction in the indexed mitral valve diameter (58.2+/-22.9 vs. 47.3+/-18.9 mm/m2, P<0.05) and Z-value (3.3+/-2.3 vs. 0.79+/-2.2, P<0.05). One patient underwent re-repair, but no patients required mitral valve replacement during the median follow-up period of 95 months. The latest regurgitation grade was absent or I in 4 patients, II in 10 patients, and III in 3 patients. Mitral valve annulus increased by 23% at 3 years and by 49% at 5 years compared with that at surgery. Mitral valve repair without the use of prosthetic materials is feasible for the majority of patients and carries an appropriate growth pattern of the mitral valve annulus after surgery.     

Current status of surgery for rheumatic carditis in children

Background

The incidence of rheumatic heart disease (RHD) has increased recently in the western United States. We reviewed our 18-year surgical experience with RHD in children to examine current surgical techniques and results.

Methods

From 1985 until 2003, 596 children (<21 years) with rheumatic fever were seen at Primary Children's Medical Center. Rheumatic carditis was diagnosed in 366 patients (61.4%). Twenty-six with carditis (26/366, 7.1%) required operation for rheumatic valve disease including 8 for mitral regurgitation, 7 for mitral and aortic regurgitation, 4 for aortic regurgitation, 4 for mitral regurgitation and stenosis, 2 for combined mitral stenosis and regurgitation with aortic insufficiency, and 1 for mitral and tricuspid regurgitation.

Results

Mean age at operation was 13.5 ± 4 years. Three patients required operation during the acute phase of rheumatic fever (< 6 weeks), 2 during the subacute phase (< 6 months), and 21 during the chronic phase after the episode of rheumatic fever (6.7 ± 3 years). Mitral valve repair was possible in 19 of 22 patients who required mitral operation. Aortic valve repair was possible in 4 patients whereas replacement was necessary in 9, including 2 Ross procedures. No operative deaths were recorded and 2 late deaths occurred at 4.6 and 10 years. Actuarial survival was 94% at 5 years and 78% at 10 years. Six patients required reoperation; actuarial freedom from reoperation was 78% at 5 years, 65% at 10 years, and 49% at 15 years. All survivors are in New York Heart Association class I or II.

Conclusions

Children with RHD in the United States uncommonly require valve operation. Mitral repair with a technique that allows annular growth is possible in most children with good long-term functional results. Long-term surveillance of children with RHD is necessary because of the possible need for late valve operation.     

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency

BACKGROUND: This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS: From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS: All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS: Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.     

Heart valve replacement in children

Twenty children with heart valve disease were operated upon and underwent heart valve replacement between 1965 and 1968. Thirteen were girls and seven boys. At the time of operation their ages ranged from 3 to 16 years. All the patients were in classes III or IV prior to operation. Three children suffered from congenital valvular lesions and 17 from rheumatic lesions. In each patient left and/or right heart catheterization and angiographic studies were performed. Six patients underwent aortic valve replacement, 11 mitral, 1 tricuspid, and 2 double valve replacement. Mitral annuloplasty was performed in addition to aortic valve replacement in two patients, and tricuspid annuloplasty in addition to mitral valve replacement in another patient. In 19 patients a prosthetic valve was used and in one an aortic heterograft (pig). Two patients died in the early postoperative period (10%), and two later, two and nine months after surgery (10%). Postoperative thromboembolism occurred in four patients (20%). All have completely recovered. All the surviving 16 patients have been followed for a period of one to four and a half years and all showed significant clinical improvement; all children of school age have returned to school and/or other normal actitivies. The overall result has been encouraging and might justify a more aggressive approach in the management of valvular diseases in this specific group of patients.     

Reconsiderations of mitral stenosis: rheumatic mitral valve repair and the Wilkins score

Background  

Mitral valve repair is a feasible treatment option in patients with rheumatic mitral valve disease, but it is not always successful. Mitral valve replacement is generally the surgical treatment of choice in such patients. We aimed to examine whether the Wilkins score can predict the feasibility of surgical repair in such patients.     

Hemolysis after mitral valve repair: mechanisms and treatment

BACKGROUND: The objectives of this study were to determine the mechanisms of hemolysis after mitral valve repair and to determine outcomes after surgical treatment (mitral replacement or re-repair). METHODS: Between 1981 and 2002, 32 patients (mean age, 58 years) presented with hemolytic anemia after mitral valve repair for degenerative, rheumatic, or ischemic mitral regurgitation (MR). Three types of annuloplasty were used at the initial mitral valve repair: Cosgrove-Edwards, Carpentier-Edwards, and bovine pericardial (Perigard). The diagnosis and the mechanisms of hemolysis were investigated with laboratory testing and echocardiography. RESULTS: Median interval from initial mitral valve surgery to diagnosis of hemolysis was 3 months (range, 1 week to 4 years). At presentation, mean hematocrit was 27.5% +/- 4.9% and 22 patients (69%) required transfusion. Echocardiographic findings varied. Twenty-four patients (77%) had grade 3 or 4 MR. Mitral regurgitant jet types included fragmentation (11 patients, 34%), acceleration (10, 31%), slow deceleration (5, 16%), collision (4, 13%), and free jet (2, 6%). Mitral valve replacement was performed in 28 patients, mitral valve re-repair in 3, and 1 patient did not undergo reoperation. At reoperation the mitral valve repair was physically intact in 25 of 31 patients (81%). There were 2 hospital deaths in patients having reoperation (6%). Actuarial survival was 95% at 1 year and 85% at 5 years. In 1 patient recurrent mechanical hemolysis developed caused by a perivalvular leak after mitral valve replacement. CONCLUSIONS: Hemolysis is a mode of failure of mitral valve repair. Patients with hemolysis generally present within 3 months of mitral valve repair. Although echocardiographic features varied, most patients had high-grade MR and regurgitant jets that fragmented or accelerated. Mitral valve replacement yields favorable outcomes for patients with hemolysis after mitral valve repair.     

Long-term results after surgical repair of incomplete endocardial cushion defects

Since 1964, 56 children (mean age, 6.7 years) underwent repair of incomplete endocardial cushion defects. Forty patients had isolated ostium primum defects. Additional congenital defects were present in 17 patients (30%). All patients underwent patch closure of the ostium primum defect and 47 of 56 patients (84%) underwent mitral valvuloplasty. Hospital mortality was 1.8% (one death). Arrhythmias developed in 7 other patients in the early postoperative period, of which six were transient and resolved completely. One patient required early pacemaker placement for complete heart block. Cumulative follow-up was 378 patient-years. There were three late deaths (5.7%), and additional operations were required in 12 patients (22.6%). Seven of these 12 patients required mitral valve replacement for severe mitral regurgitation. The mean interval between initial repair and mitral valve replacement was 4.2 years, with only three valves needing replacement within 12 months. There was a significant correlation between the severity of mitral regurgitation before initial repair and subsequent need for mitral valve replacement. Late onset atrial arrhythmias have developed in 6 patients. Current functional status has been evaluated in 50 of 52 surviving patients and 88.5% are in NYHA class I, with the remainder in class II.     

Long-term results of mitral valve repair

(1) Carpentier techniques of repair are the dominant method today because of durability and reproducible results. (2) Mitral valve repair results in high survival, low risk of anticoagulant-related complications, and low risk of infective endocarditis. (3) Long-term anticoagulation is avoided in approximately half of the patients; yet, over the long term, thromboembolism occurs significantly less with repair than with valve replacement. (4) The rate of reoperation after mitral valve repair is not significantly different from that of mechanical valve replacement up to 10 postoperative years. (5) Mitral valve repair for degenerative mitral regurgitation results in a higher freedom from reoperation at 5 years and beyond, compared with rheumatic causes of regurgitation. (6) Ischemic and congenital etiologies for mitral regurgitation demand repair whenever feasible. Results in these patient groups favor repair over other options.     

Prophylactic mitral reconstruction for mitral regurgitation

BACKGROUND: Mitral regurgitation (MR) will produce myocardial dysfunction. The goal of this study was to review outcomes of mitral valve reconstruction in asymptomatic patients with severe MR. METHODS: From 1992 to 2000, 93 asymptomatic patients with degenerative disease and severe MR underwent mitral valve reconstruction. Mean preoperative left ventricular internal diameter diastole was 56 +/- 8 mm and ejection fraction was 60% +/- 6%. Mean age was 47 +/- 10 years and mean follow-up 23 +/- 27 months. All patients underwent complex reconstruction. RESULTS: There were no deaths and two late reoperations. One was for systolic anterior motion of the anterior leaflet of the mitral valve requiring valve replacement and one for hemolysis requiring re-repair. There was one perioperative transient ischemic attack and no late thromboembolic events. At follow-up all but 1 patient remains in NYHA class I and all had no MR except in 2 patients at 63 and 89 months. CONCLUSIONS: Mitral valve reconstruction for "asymptomatic" MR can be performed with no mortality and low morbidity before development of left ventricular dysfunction. Early prophylactic repair is advocated in the presence of severe MR if valve reparability is assured.     

Outcomes of mitral valve replacement in children: a competing-risks analysis

OBJECTIVE: We sought to define patient characteristics, outcomes, and associated factors after mitral valve replacement in children. METHODS: We included 104 children undergoing at least one mitral valve replacement between 1980 and 2003 and reviewed clinical records. Competing-risks methodology was used to determine time-related prevalence and associated risk factors after initial mitral valve replacement for death and repeat replacement. RESULTS: The underlying mitral valve disease was congenital in 83%, rheumatic in 13%, Marfan syndrome in 3%, and isolated endocarditis in 1%, with 64% having primarily regurgitation, 16% having stenosis, 20% having both, and 32% having undergone previous valvotomy, valvuloplasty, or repair. There were 137 valve replacements, with 26 patients having more than one. Valve prosthesis type was St Jude Medical in 37%, Bjork-Shiley in 25%, Carbomedics in 20%, Ionescu-Shiley in 10%, and other types in 8%. Both early and late complications were common. Median age at the initial replacement was 5.9 years (range, birth to 19 years). Competing-risks analysis predicted 19% to have died at 15 years after initial replacement, with risk factors including noncongenital valve morphology, lower weight, and longer duration of cardiopulmonary bypass. A repeat replacement was predicted for 71%, with risk factors including the presence of multiple left-heart obstructive lesions and Ionescu-Shiley valve prosthesis. CONCLUSIONS: Mitral valve replacement might be necessary in children with extremely dysplastic valves and severe hemodynamic impairment or after failed repair. However, with the appropriate selection of the prosthetic valve and reduction of cardiopulmonary bypass time, surgeons might decrease mortality and increase prosthesis longevity.     

Reoperation in mitral valve repair for regurgitant mitral valve disease

Objectives: Reviewing reoperative mitral valve repair, we evaluated a predictor for future reoperation by comparing degenerative and rheumatic mitral regurgitation. Methods: From June 1988 to September 2002, 159 patients with mitral valve regurgitation underwent a variety of surgical reconstruction. Our 9 subjects −2 men and 7 women with a mean age of 55.3 years—including 1 undergoing initial repair at an other hospital, underwent reoperation for mitral valve lesions. Four patients had rheumatic (Group R) and 5 degenerative (Group D) mitral valve disease. We studied reoperative outcomes and initial procedures were retrospectively. Results: The mean interval from initial repair was 111 months. Mitral valve lesions at reoperation in Group D were annular dilation in 3, leaflet prolapse in 1, and suture disruption in 1, while that in Group R involved severe thickening of both leafle. Rerepair was possible in 3 patients of Group D, but all others, (including Group R patients) required valve replacement. All survived reoperation. Conclusions: Rerepair in rheumatic mitral regurgitation, rerepair was difficult. In degenerative mitral valve regurgitation, however, rerepair was possible because procedure-related origin was a major cause of reoperation. Reoperation can be prevented by proper technical improvement at initial repair.     

Mitral insufficiency due to ruptured chordae tendineae--clinical features, early and late results of valve replacement and repair

To evaluate the early and late results of mitral valve replacement and reconstruction for mitral insufficiency due to ruptured chordae tendineae respectively, 74 consecutive cases were analyzed. Fifty-five (74.3%) of the patients were men, and the mean age was 48 +/- 12 years old (range 16 to 76). The causes of the mitral disease were idiopathic in 50 (67.6%), rheumatic in 7 (9.4%) and infective endocarditis in 11 (14.9%) patients. In idiopathic 50 cases, 24 had mitral valve prolapse and 16 had both mitral valve prolapse and hypertension. Forty-one (55.4%) of the patients were in NYHA functional class III or IV preoperatively. Thirty (40.5%) cases underwent surgery within one year after their initial symptoms of heart failure onsets including six emergency operation cases due to uncontrollable acute lung edema. Chordae to anterior mitral leaflet were ruptured in 31 (a5, m16, p10)[41%] patients, to the posterior mitral leaflet in 45 (a4, m23, p18)[59%], and to both leaflets in one patient. Mitral valve replacement was performed in 68 patients (91.9%) and 6 patients (8.1%) underwent mitral valve repairs. Twenty cases underwent associated procedures that included tricuspid valve annuloplasty in 8, aortic valve replacement in 5 and myocardial revascularization in 4 cases. There were two operative deaths (2.4%); both occurred after replacement, left ventricular rupture in one and DIC in one. Mean follow-up period was 4.5 years (range 1 to 17) in 67 cases. There were four late deaths; all occurred after replacement. However five patients sustained mild mitral insufficiency after mitral valve repair including one that became worse of regurgitation three years after isolated Kay's annuloplasty, there were no cases that had needed reoperation and no late death after reconstruction. Left ventricular function and pulmonary arterial pressure were almost normalized in more than 90% cases postoperatively. Our data indicated that mitral valve reconstruction (McGoon's plus Kay's method as standardized maneuver) was the procedure of choice for selected patients with mitral insufficiency owing to ruptured chordae tendineae to the posterior mitral leaflet, including more limited patients with ruptured chordae to the anterior mitral leaflet.     

Mitral valve repair in children with rheumatic heart disease

OBJECTIVE: The purpose of this study was to assess the long-term results of mitral valve repair in children with chronic rheumatic heart disease. METHODS: From January 1988 through December 2003, 278 children (153 male children) underwent mitral valve repair. Mean age was 11.7 +/- 2.9 years (range, 2-15 years). One hundred seventy-three children (62%) were in the New York Heart Association functional class III or IV. Congestive heart failure was present in 24 (8.6%). Reparative procedures included posterior collar annuloplasty (n = 242), commissurotomy (n = 187), cusp-level chordal shortening (n = 94), cusp thinning (n = 71), cleft suture (n = 65), and cusp excision or plication (n = 10). Associated procedures included atrial septal defect closure (n = 22), aortic valve repair/replacement (n = 13), and tricuspid valve repair (n = 3). RESULTS: Early mortality was 2.2% (6 patients). Preoperative left ventricular dysfunction was associated with greater mortality. Median follow-up was 56.5 months (mean, 58.9. +/- 32.3 months; range, 5 to 180 months). One hundred seventy-seven survivors (65%) had no or trivial mitral regurgitation. Sixteen patients (6%) required reoperation for valve dysfunction. There were 7 late deaths (2.6%). Actuarial, reoperation-free, and event-free survivals at a median follow-up of 56.5 months were 95.2% +/- 1.5%, 91.6% +/- 2.2%, and 55.9% +/- 3.5%, respectively; at 15 years, they were 95.2% +/- 1.5%, 85.9% +/- 5.9%, and 46.7% +/- 4.7%, respectively. CONCLUSION: Mitral valve repair in children with chronic rheumatic heart disease is feasible and provides acceptable long-term results.     

Midterm results of mitral valve repair with artificial chordae in children

OBJECTIVE: We have used artificial chordal replacement with expanded polytetrafluoroethylene sutures for mitral valve repair in children and reported favorable early clinical results. In this article we evaluate the midterm results of mitral valve repair with expanded polytetrafluoroethylene sutures in 39 children. METHODS: From April 1995 through September 2003, mitral valve repair with chordal replacement using expanded polytetrafluoroethylene sutures was performed in 39 patients. In all patients the preoperative grade of mitral regurgitation was moderate or more because of prolapse of the anterior mitral leaflet. The mean age and body weight at the time of the operation were 4.7 +/- 5.3 years (range, 1 month to 17.8 years) and 14.4 +/- 12.2 kg (range, 3.9-54.4 kg), respectively. The number of expanded polytetrafluoroethylene sutures ranged from 1 to 3 (mean, 1.4). The mean follow-up period and body weight at the latest follow-up were 5.0 +/- 2.3 years (range, 1.1-8.5 years) and 25.7 +/- 16.4 kg (range, 6.9-73 kg), respectively. RESULTS: There were no operative or late deaths. Only one patient required mitral valve replacement, which occurred 17 days after repair. Two patients underwent redo mitral valve repair 2 and 5 years after initial repair, respectively. The actuarial freedom from reoperation at 5 and 8 years was 94.8% and 89.5%, respectively. At the latest follow-up, trivial or less mitral regurgitation was observed in 33 (84.6%) patients. CONCLUSIONS: Mitral valve repair with expanded polytetrafluoroethylene sutures in children demonstrated favorable midterm outcome. The procedure is safe and effective, with potential for patients' growth.     

二尖瓣主动脉瓣三尖瓣同时置换治疗重症风湿性瓣膜病

目的　总结二尖瓣主动脉瓣三尖瓣同期置换治疗重症风湿性心脏瓣膜病的手术疗效。方法　 1999年 6月至 2 0 0 1年 6月 94 1例病人进行瓣膜置换术 ,其中 2 4例同期进行二尖瓣、三尖瓣和主动脉瓣置换 ,占瓣膜置换病人的 2 5 5 %。 2 4例病人中女 17例 ,男 7例 ;年龄 18～ 5 9岁 ,平均 36岁 ;体重 37～ 5 6kg。其中 8例曾行二尖瓣闭式扩张术、11例合并左房血栓、16例病人合并有肝肿大 (肋下 2～ 8cm)和下肢水肿、8例合并有腹水。X线胸片示心胸比率为 0 6 6～ 0 91。超声检查示三尖瓣均有严重反流 ,反流面积为 4 2～ 34 0cm2 ,平均 (16 8± 9 3)cm2 。术前心功能III级 9例 ,VI级 15例。 6例病人因药物不能控制心衰而行急诊换瓣手术。结果　死亡 1例 ,死亡率为 4 2 %。术后 1周、3、6个月复查超声心动图示各心腔内径较术前明显缩小。出院者均得到随访 ,随访时间 2 0～ 36个月 ,平均 2 6 4个月。术后心功能I～II级2 0例 ,III级 4例。术后 3～ 12个月复查超声心动图未见机械瓣功能障碍及血栓形成。结论　对于联合瓣膜病变 ,三尖瓣有严重器质性病变的病人 ,在进行二尖瓣主动脉瓣置换的同时进行三尖瓣置换 ,有利于术后右心功能的恢复 ,能更好地改善心脏的血流动力学特性 ,改善心功能 ,并有利于术后病人的康