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Keizman E, Tejman-Yarden S, Hubara E, Illouz S, Katz U, Mishaly D, Serraf AE, Pollak U. The Fate of Mitral Valve Surgery in the Pediatric Age: A 25-Year Single-Center Experience. J Clin Med 2024; 13:3761. [PMID: 38999327 PMCID: PMC11242561 DOI: 10.3390/jcm13133761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The aim of this study was to evaluate the natural history of patients after mitral valve intervention in the pediatric age. Methods: This is a retrospective study including all patients who underwent mitral valve surgery from 1998 to 2022. The patients' surgical reports, postoperative records, and ambulatory visits were reviewed. The endpoints of the study were survival and freedom from mitral valve reoperation. Results: Of the 70 patients included in the cohort, 61 patients (86.7%) had congenital mitral valve disease, of whom 46 patients (75.4%) had a predominantly mitral regurgitation lesion, and 15 patients (24.6%) had a predominantly mitral stenosis. In the mitral regurgitation group, all of the patients underwent valve repair with an operative mortality of one patient (2.1%), and with median follow-up of 4 years (range, 0.5-13 years), there was 4.3% mortality (n = 2) and 71.2% freedom from reoperation. In the mitral stenosis group, 11 patients underwent mitral valve repair, and 4 patients underwent valve replacement. There was an operative mortality of two patients (13.3%). With a 2-year median follow-up (range: 0.1-23 years), there were no additional mortality cases in the mitral stenosis group. All three patients who survived primary mitral valve replacement (100%) and four patients who survived a primary repair (40.0%) underwent reoperation. Conclusions: This study demonstrates encouraging outcomes for mitral valve repair. The mortality of patients with congenital mitral valve disease may also be related to a difficult postoperative course, rather than the MV lesion itself.
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Affiliation(s)
- Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Ramat-Gan 5266202, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat-Gan 5266202, Israel
| | - Shai Tejman-Yarden
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat-Gan 5266202, Israel
| | - Evyatar Hubara
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat-Gan 5266202, Israel
| | - Shay Illouz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Uriel Katz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat-Gan 5266202, Israel
| | - David Mishaly
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat-Gan 5266202, Israel
| | - Alain E. Serraf
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat-Gan 5266202, Israel
- Pediatric Critical Care Unit, Hadassah University Medical Center, Ein Kerem, Jerusalem 91240, Israel
- The Hebrew University Hadassah Medical School, Jerusalem 9112002, Israel
| | - Uri Pollak
- Pediatric Critical Care Unit, Hadassah University Medical Center, Ein Kerem, Jerusalem 91240, Israel
- The Hebrew University Hadassah Medical School, Jerusalem 9112002, Israel
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2
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Honjo O, Chetan D, Fan CPS, Kadowaki S, Marshall AC, Chaturvedi RR, Benson L, Dipchand AI, Seed M, Haller C, Barron DJ. Surgical Melody Mitral Valve: A Paradigm Shift for Infants With Unrepairable Mitral Valve Disease. Ann Thorac Surg 2024:S0003-4975(24)00384-9. [PMID: 38810907 DOI: 10.1016/j.athoracsur.2024.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/11/2024] [Accepted: 04/22/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND The Melody valve (Medtronic, Minneapolis, MN) for mitral valve replacement (MVR) (MelodyMVR) has been an effective strategy to treat unrepairable mitral valve disease in small children. This study analyzed survival, durability, and complications of the MelodyMVR strategy. METHODS Patients who underwent MelodyMVR between 2014 and 2023 were included. Transplant-free survival was analyzed with Kaplan-Meier analysis. The Fine and Gray subdistribution method was applied to quantify the cumulative incidence. RESULTS Twenty-five patients underwent MelodyMVR. Median age and weight were 6.3 months (interquartile range, 4.4-15.2 months) and 6.36 kg (interquartile range, 4.41-7.57 kg). Fifteen patients (60%) had congenital mitral valve disease and 13 (52%) had dominant mitral regurgitation. The median diameter of the implanted Melody was 16 mm (interquartile range, 14-18 mm). Mortality at 6 months, 1 year, and 5 years was 8.3% (95% CI, 2.2%-29.4%), 12.5% (95% CI, 4.2%-33.9%), and 17.6% (95% CI, 7.0%-40.7%), respectively. Two hospital survivors (8%) required early Melody replacement. Competing risk analysis showed that ∼50% of patients underwent mechanical MVR by 3.5 years after MelodyMVR. Freedom from bleeding and thrombosis at 4 years was 87.5% (95% CI, 74.2%-100%). Eleven patients underwent subsequent mechanical MVR with no deaths. One (9%) required pacemaker implantation after mechanical MVR. CONCLUSIONS MelodyMVR provides reasonable early and medium-term survival in small children and a high rate of successful bridge to mechanical MVR. MelodyMVR is associated with minimal pacemaker requirement, bleeding, and thrombosis. Early Melody functional deterioration necessitates early repeat MVR, which can be achieved with minimal morbidity and mortality.
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Affiliation(s)
- Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Devin Chetan
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po S Fan
- Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Sachiko Kadowaki
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Audrey C Marshall
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Rajiv R Chaturvedi
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lee Benson
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Anne I Dipchand
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Recco DP, Kneier NE, Earley PD, Kizilski SB, Hammer PE, Hoganson DM. Fiberscope-Based Measurement of Coaptation Height for Intraoperative Assessment of Mitral Valve Repair. World J Pediatr Congenit Heart Surg 2024; 15:371-379. [PMID: 38327093 DOI: 10.1177/21501351231221459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND Restoring adequate coaptation height is a key principle of mitral valve (MV) repair. This study aimed to evaluate the utility of fiberscope (FS) technology to assess MV coaptation height for intraoperative use. METHODS Ex-vivo testing was performed on five adult porcine hearts. The left atrium (LA) was resected, and the left ventricle (LV) was pressurized retrograde to 27 ± 1mm Hg. An endoscope was inserted into the LV apex, centered under the MV orifice. An FS system (Milliscope II camera, LED light source, and 0.7 mm diameter × 15 cm long) 90° semirigid scope with 1.2 mm focal length) was mounted above the MV annulus in a custom alignment and measuring fixture. Three blinded measurements were taken at two locations on each MV, A2 and P2 segment, from the top of coaptation to the leaflet edge identified by the FS. Accurate positioning was verified using the LV endoscope. A control (metal rod of similar thickness) was used for comparison, with coaptation height recorded when the control was seen via the endoscope. RESULTS Coaptation heights were similar for the control and FS methods across all hearts at A2 (11.6 ± 2.6 mm control vs 11.8 ± 2.2 mm FS) and P2 (13.3 ± 2.6 mm control vs 13.4 ± 2.9 mm FS) segments, with similar measurement variability (control SD 0.1-1.0 mm; FS SD 0.1-0.9 mm). One outlier was excluded from analysis (n = 19/20). The maximum absolute difference and percent error between measurement methods were less than 1.1 mm (median [IQR], 0.6 [0.3-0.9] mm) and less than 14% (4.1 [2.2-7.6]%). CONCLUSIONS Utilization of a miniaturized FS enabled precise and accurate quantification of MV coaptation. This technique is promising for evaluating post-repair valve competence and coaptation height.
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Affiliation(s)
- Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nicholas E Kneier
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Patrick D Earley
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Shannen B Kizilski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Peter E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Rahmat B, Siswanto BB, Fakhri D, Sakidjan I, Murni TW, Timan IS, Kekalih A, Kurniawati Y, Fardhani DG, Arya Wardana PW. Posterior Annulus Elevation Technique in Reducing Residual Regurgitation During Mitral Valve Repair in Children: A Randomized Controlled Trial. World J Pediatr Congenit Heart Surg 2024; 15:353-362. [PMID: 38145581 DOI: 10.1177/21501351231211590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
Background: The current technique used in severe mitral regurgitation in children can occasionally lead to residual regurgitation. To address this issue, the posterior annulus elevation technique was developed to enhance coaptation and reduce residual lesions. This study aims to evaluate the effectiveness of this technique in reducing residual regurgitation during mitral valve repair in children. Methods: A total of 64 patients aged <18 years old undergoing mitral valve repair were randomized into two groups: the intervention (with posterior annulus elevation) group and the control group, which underwent conventional repair techniques. Various parameters, including coaptation area, residual mitral regurgitation, clinical outcomes, metabolic, and hemolytic markers, were measured on days 0, 5, 2 weeks, and 3 months after surgery. Results: The intervention group (n = 32) showed a significant reduction in residual mitral regurgitation compared with the control group (n = 32) on each evaluation. At three months after surgery, we found that the posterior annulus elevation technique could be a protective factor that reduces the chance of residual regurgitation compared with the control group (RR = 0.31; confidence interval: 0.18-0.54; P ≤ .001). Coaptation length and index were also found to be significantly higher in the intervention group (P ≤ .001). Clinical outcomes, metabolic markers, and hemolysis marker did not show any significant differences between the two groups. Conclusions: The posterior annulus elevation technique demonstrated effectiveness in reducing residual mitral regurgitation and improving coaptation area in pediatric mitral valve repair. This technique showed better short-term surgical outcomes in children with mitral regurgitation compared with the conventional technique.
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Affiliation(s)
- Budi Rahmat
- Doctoral Program in Medical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Bambang Budi Siswanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Centre Harapan Kita, Jakarta, Indonesia
| | - Dicky Fakhri
- Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Indriwanto Sakidjan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Centre Harapan Kita, Jakarta, Indonesia
| | - Tri Wahyu Murni
- Cardiothoracic Surgery Division, Department of Surgery, Hasan Sadikin Hospital, Jawa Barat, Indonesia
| | - Ina Susianti Timan
- Human Genetic Research Center IMERI-FKUI, Universitas Kristen Krida Wacana, Jakarta, Indonesia
| | - Aria Kekalih
- Community Medicine Department, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Yovi Kurniawati
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Centre Harapan Kita, Jakarta, Indonesia
| | - Dwi Gunawan Fardhani
- Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Putu Wisnu Arya Wardana
- Department of Thoracic, Cardiac and Vascular Surgery, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Liddle D, Gearhart A, Sleeper LA, Lu M, Feins E, Schidlow DN, Ghelani S, Powell AJ, Emani S, Beroukhim RS. Mitral valve orifice area predicts outcome after biventricular repair in patients with hypoplastic left ventricles. J Cardiovasc Magn Reson 2024; 26:101029. [PMID: 38403073 PMCID: PMC10965470 DOI: 10.1016/j.jocmr.2024.101029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Identification of risk factors for biventricular (BiV) repair in children with hypoplastic left ventricles (HLV) has been challenging. We sought to identify preoperative cardiovascular magnetic resonance (CMR) predictors of outcome in patients with HLVs who underwent BiV repair, with a focus on the mitral valve (MV). METHODS Single-center retrospective analysis of preoperative CMRs on patients with HLV (≤50 mL/m2) and no endocardial fibroelastosis who underwent BiV repair from 2005-2022. CMR measurements included MV orifice area in diastole. The primary composite outcome included time to death, transplant, BiV takedown, heart failure admission, left atrial decompression, or unexpected reoperation; and the secondary outcome included more than or equal to moderate mitral stenosis and/or regurgitation. RESULTS Median follow-up was 0.7 (interquartile range 0.1, 2.2) years. Of 122 patients [59 atrioventricular canal (AVC) and 63 non-AVC] age 3 ± 2.8 years at the time of BiV repair, freedom from the primary outcome at 2 years was 53% for AVC and 69% for non-AVC (log rank p = 0.12), and freedom from the secondary outcome at 2 years was 49% for AVC and 79% for non-AVC (log rank p < 0.01). Independent predictors of primary outcome for AVC patients included MV orifice area z-score <-2 and transitional AVC; for non-AVC patients, predictors included MV orifice area z-score <-2, abnormal MV anatomy, and conal-septal ventricular septal defect. Independent predictors of secondary outcome for AVC patients included older age at surgery, transitional AVC, and transposition of the great arteries. CONCLUSION In children with HLV, low MV orifice area and pre-existing MV pathology are risk factors for adverse outcome after BiV repair.
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Affiliation(s)
- David Liddle
- The Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
| | - Eric Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA.
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sunil Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA.
| | - Rebecca S Beroukhim
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Elsisy MF, Dearani JA, Ashikhmina E, Aganga DO, Taggart NW, Todd A, Stephens EH. National In-Hospital Outcomes of Mechanical Mitral Valve Replacement in the Pediatric Population. World J Pediatr Congenit Heart Surg 2024; 15:37-43. [PMID: 37551083 DOI: 10.1177/21501351231185118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Background: National data about the outcomes of children undergoing mechanical mitral valve replacement (m-MVR) are scarce. Methods: A retrospective review of hospitalizations from the Kids' Inpatient Database was performed for patients ≤18 years of age in the United States. A total of 500 patients underwent m-MVR in 2009, 2012, 2016, and 2019. Patients with single ventricle physiology were excluded (n = 13). These patients were categorized into three groups according to age: neonates (<1 month, n = 20), infants (1-12 months, n = 76 patients), and children (1-18 years, n = 404). Outcomes were compared between the three groups. Results: The proportion of m-MVR involving children undergoing MV procedures (repair and replacement) has increased from 17.3% in 2009 to 30.8% in 2019 (Ptrend < .01). History of cardiac surgery was present in 256 patients (51.2%). Concomitant procedures were performed in 119 patients (23.8%). Intra- or postoperative extracorporeal membrane oxygenation was required in 19 patients (3.8%). The overall in-hospital mortality was 4.8% and was significantly higher in neonates and infants compared with older children (10% vs 11.8% vs 3.2%, P = .003). The length of hospital stay was longer in the neonatal group (median, 57 days, interquartile range, [24.8-90] vs 29.5 days [15.5-61] vs 10 days [7-18], P < .01). Nonhome discharges were more common in neonates and infants (40% vs 36.8% vs 13.1%, P < .01). Conclusion: Mechanical mitral valve replacement is increasingly performed over time with acceptable in-hospital morbidity and mortality, especially in older children and adolescents. Neonates and infants are associated with worse hospital survival, prolonged hospitalization, and significant rates of nonhome discharges.
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Affiliation(s)
- Mohamed F Elsisy
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Elena Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Devon O Aganga
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nathaniel W Taggart
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Austin Todd
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Services, Mayo Clinic, Rochester, MN, USA
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Cai Y, Jiang N, Chen G, Mi Y, Zhong H, Jia B, Zhang H, Ye M. Risk factors for mitral valve dysfunction, reoperation and death following repair of the primary mitral valve disease in children. J Thorac Dis 2023; 15:4154-4171. [PMID: 37691651 PMCID: PMC10482615 DOI: 10.21037/jtd-23-270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/30/2023] [Indexed: 09/12/2023]
Abstract
Background After primary mitral valve (MV) repair, residual mitral valve regurgitation (MR) and recurred mitral valve stenosis (MS) are the principal occurrences. This study's purpose is to identify the risk factors of MV dysfunction, reoperation and death following repair of primary MV diseases. Methods We retrospectively reviewed 98 patients (47 males and 51 females) with primary MV diseases between January 2013 and December 2021. The median age was 34 months [interquartile range (IQR), 11.4-59] for male and 24 months (IQR, 7.35-72) for female. The left ventricular ejection fraction (LVEF), the left ventricular end-diastolic volume index (LVEDVI) and left ventricular end-systolic volume index (LVESVI) were assessed to evaluate patient's left ventricular function. Risk factors that increased the likelihood of MV dysfunction, reoperation and death after surgery were investigated. Results During the 23.5 months (IQR, 9-44.5) of follow-up, 5 (5.1%) patients died, including one early death and two late deaths (n=3; 3.9%) in the MR group and one early death and one late death (n=2; 9.1%) in the MS group. Seven (9.2%) patients in the primary MR disease group and 2 (9.1%) patients in the primary MS disease group required a second MV operation for a total reoperation rate of 9.2% (9/98). As of the most recent follow-up, 34 patients experienced MV dysfunction. No significant difference was recorded between primary MR and MS disease groups in Kaplan-Meier freedom from MV dysfunction and reoperation. Mixed MV pathology (P=0.014) acted as an independent risk factor for MV dysfunction, and ≥ moderate MR at 24 h after first surgery (P=0.014) an independent risk factor for MV reoperation. Double-orifice MV technique (P=0.002), MV reoperation (P=0.023) and severe MR at 24 h after first surgery (P=0.028) were independent risk factors for death. Conclusions The Kaplan-Meier freedom from MV dysfunction and reoperation were comparable between primary MR and MS disease groups. A high probability of MV dysfunction was predicted due to the mixed MV pathology. Patients with ≥ moderate MR at 24 h after first surgery had a higher risk of MV reoperation. Double-orifice MV technique, MV reoperation and severe MR at 24 h after first surgery had a higher risk for death.
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Affiliation(s)
- Yixuan Cai
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Na Jiang
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Gang Chen
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Yaping Mi
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Hui Zhong
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Bing Jia
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Huifeng Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Ming Ye
- Department of Cardiothoracic Surgery, Children's Hospital of Fudan University, Shanghai, China
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8
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Si MS, Sood V, Biniwale R, Peng D. Considerations of valvular heart disease in children with ventricular assist devices. Front Cardiovasc Med 2023; 10:1056663. [PMID: 37034354 PMCID: PMC10075362 DOI: 10.3389/fcvm.2023.1056663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
Ventricular assist devices have become a valuable tool in the treatment of heart failure in children. The use of ventricular assist devices has decreased mortality in children with end-stage heart failure awaiting transplant. It is not uncommon for children with end-stage heart failure associated with cardiomyopathy or congenital heart disease to have significant systemic semilunar and atrioventricular valve regurgitation, which can impact the efficiency and efficacy of hemodynamic support provided by a ventricular assist device. Therefore, implanting clinicians should carefully assess for valve abnormalities that may need repair and impact device selection and cannulation strategy to effectively support this diverse population. The purpose of this review is to provide an overview of this important and relevant topic and to discuss strategies for managing these patients.
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Affiliation(s)
- Ming-Sing Si
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
- Correspondence: Ming-Sing Si
| | - Vikram Sood
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
| | - Reshma Biniwale
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
| | - David Peng
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, Mattel Children’s Hospital, Los Angeles, CA, United States
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9
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Reed AK, Chiu P, Carreon CK, Sanders SP, Del Nido PJ, Baird CW. Unrepairable Infant Mitral Valve: An Unexpected Case of Decompensated Heart Failure. Circulation 2022; 145:1175-1178. [PMID: 35404678 DOI: 10.1161/circulationaha.121.056881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Peter Chiu
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
| | - Chrystalle Katte Carreon
- Department of Pathology (C.K.C., S.P.S.), Boston Children's Hospital/Harvard Medical School, MA.,Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, MA (C.K.C., S.P.S.)
| | - Stephen P Sanders
- Department of Pathology (C.K.C., S.P.S.), Boston Children's Hospital/Harvard Medical School, MA.,Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, MA (C.K.C., S.P.S.)
| | - Pedro J Del Nido
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
| | - Christopher W Baird
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
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10
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6552799. [DOI: 10.1093/ejcts/ezac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 11/12/2022] Open
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Brancaccio G, Trezzi M, Chinali M, Vignaroli W, D'Anna C, Iodice F, Giorni C, Iacobelli R, Iorio F, Galletti L, Croci I, Carotti A. Predictors of survival in paediatric mitral valve replacement. Eur J Cardiothorac Surg 2021; 60:361-366. [PMID: 33582753 DOI: 10.1093/ejcts/ezab078] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/08/2021] [Accepted: 01/13/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of this study was to identify the predictors of death and of reintervention after mitral valve replacement (MVR) in children. METHODS A single-centre retrospective study was performed including 115 patients under the age of 18 undergoing MVR between 1982 and 2019. For all patients, the ratio of prosthetic valve size (diameter in mm) to weight (kg) at surgery was calculated and long-term result was assessed. The primary outcome was freedom from mitral valve (MV) re-replacement. The composite secondary outcome was freedom from death or transplant. RESULTS Fifty-four patients had a previous surgical attempt to MV repair. The median age at surgery was 5.5 years (interquartile range 1.21-9.87). Death/transplant-free survival was 77 ± 4% at 5 years and 72 ± 5% at 10 years. Univariate analysis showed a size/weight ratio higher than 2 and age <2 years as significant risk factors for death or transplant. Freedom from MV re-replacement at 5 and 10 years was 90 ± 3% and 72 ± 6%, respectively. Biological prosthesis implanted at first replacement (P = 0.007) and size/weight ratio higher than 2 (P = 0.048) were predictors of reoperation. Significant upsizing (P < 0.0001) of mitral prosthesis was observed at re-replacement. CONCLUSIONS MVR is a viable strategy in children with unrepairable MV disease. Mortality can be predicted based on size/weight ratio and age <2 years. MV re-replacement can be performed with low morbidity and mortality and a larger-size prosthesis can often be placed at the time of redo.
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Affiliation(s)
- Gianluca Brancaccio
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Matteo Trezzi
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Marcello Chinali
- Department of Pediatric Cardiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Walter Vignaroli
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Carolina D'Anna
- Department of Pediatric Cardiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesca Iodice
- Department of Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Chiara Giorni
- Department of Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Roberta Iacobelli
- Department of Pediatric Cardiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Fiore Iorio
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lorenzo Galletti
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Ileana Croci
- Predictive and Preventive Medicine Research Unit, Multifactorial and Complex Disease Research Area, Bambino Gesù Children's Hospital, Rome, Italy
| | - Adriano Carotti
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
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Abstract
Data on mitral valve replacement (MVR) in young children is still limited. Our objective was to evaluate MVR in children below 5 years and identify factors affecting the outcomes. This retrospective study included 29 patients who had MVR from 2002 to 2020. We grouped the patients into two groups according to their age: age ≤ 24 months (n = 18) and > 24 months (n = 11). Primary cardiac diagnoses were Shone complex (n = 7; 24%), isolated congenital mitral valve abnormality (n = 11; 38%), and complete atrioventricular septal defect (n = 3; 10%). The median age was 19 month (25th–75th percentile: 11–32) and 59% were females (n = 17). The hemodynamic lesions were mitral regurgitation in 66%, mitral stenosis in 10%, and combined mitral stenosis and regurgitation in 24% of the patients. St. Jude mitral valve was the most common valve implanted (n = 19, 66%), followed by CarboMedics in 21% of the patients (n = 6). The mitral valve was implanted in the supra-annular position in 6 cases (21%). Preoperative and operative data were comparable between both groups. There was no association between valve size and position with postoperative heart block (P > 0.99, for both). The median follow-up duration was 19.4 months (8.6–102.5). Nine patients had mitral valve reoperation, six had MVR, and three had clot removal from the mitral valve. There was no effect for age group on reoperation (SHR 0.89 (95% CI 0.27–2.87), P = 0.84). Valve size significantly affected reoperation (SHR 0.39 (95% CI 0.18–0.87), P = 0.02). The supra-annular position was associated with an increased risk of reoperation (SHR 3.1 (95% CI 1.003–9.4), P = 0.049). There was no difference in survival according to the age (Log-rank P = 0.57) or valve size (Log-rank P = 0.66). Mitral valve replacement in children is associated with low morbidity and mortality. The risk of reoperation could be affected by the valve size and position rather than the age.
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Maschietto N, Prakash A, Del Nido P, Porras D. Acute and Short-Term Outcomes of Percutaneous Transcatheter Mitral Valve Replacement in Children. Circ Cardiovasc Interv 2021; 14:e009996. [PMID: 33722065 DOI: 10.1161/circinterventions.120.009996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Nicola Maschietto
- Department of Cardiology (N.M., A.P., D.P.), Boston Children's Hospital, MA
| | - Ashwin Prakash
- Department of Cardiology (N.M., A.P., D.P.), Boston Children's Hospital, MA
| | - Pedro Del Nido
- Department of Cardiac Surgery (P.d.N.), Boston Children's Hospital, MA
| | - Diego Porras
- Department of Cardiology (N.M., A.P., D.P.), Boston Children's Hospital, MA
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14
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Lehenbauer DG, Tweddell JS, Winlaw DS. Debate - Replacement of the Mitral Valve Under One Year of Age: Mechanical Valves Should Be Used. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:44-56. [PMID: 34116782 DOI: 10.1053/j.pcsu.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/01/2021] [Accepted: 03/19/2021] [Indexed: 11/11/2022]
Abstract
This article reviews the literature, focusing on publications from the third millennium and the results of mitral valve replacement in children younger than 1 year of age. Special consideration has been given to neonatal and infant valve replacement to provide insights into valve choice and technique. Mitral valve replacement is an important topic because it carries the highest mortality and poorer long-term prognosis than any other valve replacement in children.
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Affiliation(s)
- David G Lehenbauer
- Heart Institute and Department of Surgery, and the Division of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - James S Tweddell
- Heart Institute and Department of Surgery, and the Division of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Winlaw
- Heart Institute and Department of Surgery, and the Division of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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15
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Mitral Valve Repair in Children Below Age 10 Years: Trouble or Success? Ann Thorac Surg 2020; 110:2082-2087. [DOI: 10.1016/j.athoracsur.2020.02.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/16/2020] [Accepted: 02/24/2020] [Indexed: 11/19/2022]
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16
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Myers PO, Dave H, Kretschmar O, Sologashvili T, Pfister R, Prêtre R. Cylinder mitral and tricuspid valve replacement in neonates and small children. Eur J Cardiothorac Surg 2020; 58:964-968. [PMID: 32844202 DOI: 10.1093/ejcts/ezaa196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/15/2020] [Accepted: 05/05/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Atrioventricular valve replacement in small children is associated with high morbidity and mortality. There are no prostheses available with a diameter ˂15 mm. This study reports our initial experience with a cylinder valve for mitral and tricuspid valve replacement in infants and small children. METHODS Our cylinder valve was hand-made for patients requiring atrioventricuclar valve replacement with an annulus of <15 mm. A 12-mm Contegra valve was prepared and placed inside a 14-mm Gore-Tex tube graft and sutured on both extremities. RESULTS Eight patients were included, with a median age of 6.9 months (range 1 day to 38 months). Four had mitral and 4 had tricuspid valve replacement. All implants were technically successful, with no significant regurgitation, no stenosis and no left ventricular outflow tract obstruction. There were 3 early deaths from low cardiac output, in patients with significant associated lesions (severe neonatal Ebstein's, pulmonary artery-intact ventricular septum, biventricular conversion from Norwood stage 1). Two patients required early reintervention: 1 for balloon dilatation for stenosis and 1 for reoperation for paravalvular leak. During follow-up, 2 patients had mitral valve replacement with a 16-mm mechanical valve at 9 and 20 months from the cylinder valve implantation. The remaining 2 patients are alive and well 2 years and 2 months after the procedure. CONCLUSIONS Cylinder valve replacement of atrioventricular valves was feasible without any technical issues. It was successful in getting out of a difficult situation and allows for somatic growth and implantation of a reasonably-sized mechanical prosthesis on the annulus.
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Affiliation(s)
- Patrick O Myers
- Division of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Hitendu Dave
- Division of Cardiac Surgery, Zurich Children's University Hospital, Zurich, Switzerland
| | - Oliver Kretschmar
- Division of Pediatric Cardiology, Zurich Children's University Hospital, Zurich, Switzerland
| | - Tornike Sologashvili
- Division of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,Division of Cardiac Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Raymond Pfister
- Division of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - René Prêtre
- Division of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Qi L, Ma K, Zhang B, Rui L, Lin Y, Wang G, Li S. Pediatric Mitral Regurgitation: Standardized Repair-Oriented Strategy With Leaflet Plication. Semin Thorac Cardiovasc Surg 2020; 32:1002-1012. [PMID: 32505798 DOI: 10.1053/j.semtcvs.2020.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/29/2020] [Indexed: 11/11/2022]
Abstract
To introduce a standardized strategy and reproducible procedures of mitral repair for mitral regurgitation in the pediatric population with leaflet plication as a principal technique. Consecutive patients who had undergone mitral repair by our standardized repair-oriented strategy in our institution from January 2016 to December 2019 were included retrospectively. The standardized repair strategy included 3-step inspections and repair from the subvalvular to leaflet, and then to the annular level. The main surgical techniques included chordae detachment, papillary muscle splitting, leaflet plication, and posterior annuloplasty. The indication for leaflet plication was that the distance between 2 adjacent chordae tendineae was greater than 4 mm. A total of 113 patients were enrolled. During 22.6-month (range, 2-50 months) follow-up period, primary endpoint was documented in 15 (13.3%) patients, including 1 (0.9%) death, 0 transplantation, and 14 (12.4%) functional mitral failure. Freedom form primary endpoints at 6 months, 1 year, and 3 years was 94.7%, 94.7%, and 82.3%, respectively. Significant independent predictors of functional mitral valve failure were younger age (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.04-0.72; P = 0.037) and ischemic mitral regurgitation (MR) (HR, 24.34; 95% CI, 4.52-47.33; P < 0.001). Leaflet plication was significantly associated with well-functioned mitral valve (HR, 7.42; 95% CI, 2.35-30.54; P = 0.004). Compared with nonischemic MR group, ischemic MR group was noted with higher occurrence of primary endpoint events (11/28 vs 4/85, P < 0.001). The short- to mid-term outcomes of standardized mitral repair technique with leaflet plication were favorable, among which, however, repair for mitral regurgitation with ischemic lesions is comparatively challenging.
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Affiliation(s)
- Lei Qi
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Kai Ma
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Benqing Zhang
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Lu Rui
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Ye Lin
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Guanxi Wang
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Shoujun Li
- Department of Cardiac Surgery, Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China.
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18
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Double-Orifice Left Atrioventricular Valve: The Case for Preoperative Three-Dimensional Echocardiography. ACTA ACUST UNITED AC 2020; 4:248-251. [PMID: 32875190 PMCID: PMC7451879 DOI: 10.1016/j.case.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Double-orifice left AV valve complicates successful repair of common AV canal. Two-dimensional imaging may not recognize or define double-orifice left AV valve. Three-dimensional echocardiography is useful for visualizing these complex valves.
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19
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Isaacson E, Lucjak C, Johnson WK, Yin Z, Wang T, Rein L, Woods RK, Tweddell JS, Hraska V, Mitchell ME. Mitral Valve Surgery in Neonates, Infants, and Children: Surgical Approach, Outcomes, and Predictors. Semin Thorac Cardiovasc Surg 2020; 32:541-550. [PMID: 31972302 DOI: 10.1053/j.semtcvs.2020.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/12/2020] [Indexed: 11/11/2022]
Abstract
The surgical treatment of mitral disease in pediatrics is challenging. Managing diversity in patient anatomy, growth, and the need for long-term anticoagulation requires trade-offs between imperfect solutions. We sought to assess our approach to pediatric mitral valve surgery and identify predictors associated with mortality and recurrent mitral disease. The medical records, echocardiograms, and operative reports of all patients who underwent surgical intervention on the mitral valve from January 2000 to April 2016 were reviewed. A total of 143 patients underwent mitral valve surgery, 64 of which were neonates or infants (ages 10-355 days) and 79 of which were children (ages 1-17.8 years). Neonates and infants had a higher preoperative New York Heart Association heart failure classification in comparison to children (P < 0.001) with a less severe degree of mitral valve insufficiency (P = 0.007). Postoperative outcomes for primary repair patients (n = 133) demonstrated significant differences in recurrence of mitral valve disease, with 38% of neonates/infants and 21% of children affected (P = 0.028). Five-year rates of mortality or transplant were 22% (8%, 33%) in neonates and infants compared to 4% (0%, 10%) in children, P = 0.013. Mitral valve surgery in neonates and infants is particularly high risk and is associated with higher rate of recurrence and reintervention early. However, if successful early, mitral valve repair in neonates and infants can result in a durable freedom from reintervention that parallels freedom from reintervention in older children undergoing repair. Further understanding of mechanisms of failure and better matching of anatomic substrate to strategy is needed.
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Affiliation(s)
| | | | - William K Johnson
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Ziyan Yin
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tao Wang
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - James S Tweddell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Cincinnati, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Viktor Hraska
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
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20
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Outcome for Conservative Surgery for the Correction of Severe Mitral Valve Regurgitation in Children: A Single-Center Experience. Pediatr Cardiol 2019; 40:1663-1669. [PMID: 31482236 DOI: 10.1007/s00246-019-02201-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
Evolving reconstructive techniques have progressively become the preferred approach for treatment of pediatric mitral valve regurgitation. We present our experience in a cohort of patients undergoing surgical correction for severe mitral regurgitation. Fifty-five patients (age 1 month-18 years; median 5 years) were included in the present analysis. Different surgical techniques were used (posterior leaflet augmentation in 25, isolated cleft closure in 12, Alfieri-type procedure in 10, annuloplasty in 5, with artificial chordae in 2, and quadrangular resection with chordal transposition in 1). Follow-up time ranged from 1 to 192 months (median 38[IQR 12-54] months). Operative and follow-up mortality was 0%. Reintervention in the whole population occurred in 31% of patients. However, when first surgery was performed under 2 years of age (no = 17), reintervention reached nearly 50%. The degree of residual mitral regurgitation at follow-up remained stable after surgery, while a significant increase in mean transmitral gradient was observed over time (paired t test = 0.03). In multivariable Cox-regression analysis, post-surgical transmitral gradient was the only independent predictor for reintervention (p = 0.017; HR 2.4; 95%CI 1.2-5.1), after correcting for differences in age at surgery, type of reintervention, mitral annulus dimension, and BSA at the first surgery. ROC curve demonstrated that a post-surgical transmitral mean gradient value > 5 mmHg, was predictive for reintervention (AUC = 0.89; Youden index = 0.44). Our study suggests that the use of conservative technique strategy achieves satisfactory functional results in infants and children with severe MR, although the rate of reoperation in younger patients remains substantial. Post-operative moderate mitral stenosis was the strongest predictor for reoperation.
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Hawkins RB, Byler M, Fonner C, Kron IL, Yarboro LT, Speir AM, Quader MA, Ailawadi G, Mehaffey JH. Travel distance and regional access to cardiac valve surgery. J Card Surg 2019; 34:1044-1048. [PMID: 31374597 DOI: 10.1111/jocs.14199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Evidence in other surgical subspecialties suggests patients traveling farther to undergo surgery have worse outcomes. We sought to determine the impact of travel distance and travel beyond closest center on outcomes after valve surgery. METHODS Patients who underwent valve surgery ±CABG with a Society of Thoracic Surgeons (STS) predicted risk and zip code were extracted from a statewide STS database (2011-016). Patients were stratified by those receiving care greater than or equal to 20 miles from the closest surgical center (Traveler) or at the closest center (Non-Traveler). Multivariate logistic regression assessed the effects of travel distance and traveler status on mortality and major morbidity adjusted for STS predicted risk, median income by zip code, and payer status. RESULTS Median travel distance for all patients (n = 4765) was 19 miles and after risk-adjustment increasing distance was associated with reduced operative mortality (odds ratio [OR], 0.94 [0.89-1.00], P = .049) with no impact on major morbidity. Travelers (445 patients, 9.3%) had lower median income, higher self-pay and reoperative status, but similar urgent/emergent status and STS risk as Non-Travelers. Travelers had lower operative mortality (1.6% vs 4.3%, P = .005) which remained statistically lower after risk-adjustment (OR, 0.32 [0.14-0.75], P = .009). This mortality difference was particularly pronounced in patients with postoperative complications (3.1% vs 7.9%, P = .005). CONCLUSIONS Contrary to other surgical subspecialties, farther travel distance and bypassing the nearest surgical center were associated with lower rates of operative mortality and failure to rescue. Either referral patterns or financials reasons may result in Travelers ending up at high performing centers that prevent escalation of complications.
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Affiliation(s)
- Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Matthew Byler
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Clifford Fonner
- Virginia Cardiac Surgery Quality Initiative, Falls Church, Virginia
| | - Irving L Kron
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Alan M Speir
- Department of Surgery for, INOVA Heart and Vascular Institute, Falls Church, Virginia
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
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Mater K, Ayer J, Nicholson I, Winlaw D, Chard R, Orr Y. Patient-Specific Approach to Mitral Valve Replacement in Infants Weighing 10 kilograms or less. World J Pediatr Congenit Heart Surg 2019; 10:304-312. [DOI: 10.1177/2150135119837200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Mitral valve replacement (MVR) is the only option for infants with severe mitral valve disease that is not reparable; however, previously reported outcomes are not always favorable. Our institution has followed a tailored approach to sizing and positioning of mechanical valve prostheses in infants requiring MVR in order to obtain optimal outcomes. Methods: Outcomes for 22 infants ≤10 kg who have undergone MVR in Sydney, Australia, from 1998 to 2016, were analyzed. Patients were at a mean age of 6.8 ± 4.1 months (range: 0.8-13.2 months) and a mean weight of 5.4 ± 1.8 kg at the time of MVR. Most patients (81.8%) had undergone at least one previous cardiac surgical procedure prior to MVR, and 36.4% had undergone two previous procedures. Several surgical techniques were used to implant mechanical bileaflet prostheses. Results: All patients received bileaflet mechanical prostheses, with 12 receiving mitral prostheses and 10 receiving inverted aortic prostheses. Surgical technique varied between patients with valves implanted intra-annularly (n = 6), supra-annularly (n = 11), or supra-annularly with a tilt (n = 5). After a mean follow-up period of 6.2 ± 4.4 years, the survival rate was 100%. Six (27.3%) patients underwent redo MVR a mean of 102.2 ± 10.7 months after initial MVR. Four (18.2%) patients required surgical reintervention for development of left ventricular outflow tract obstruction and three (13.6%) patients required permanent pacemaker placement during long-term follow-up. Conclusions: The tailored surgical strategy utilized for MVR in infants at our institution has resulted in reliable valve function and excellent survival. Although redo is inevitable due to somatic growth, the bileaflet mechanical prostheses used displayed appropriate durability.
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Affiliation(s)
- Kathryn Mater
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Julian Ayer
- Heart Centre for Children, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Ian Nicholson
- Heart Centre for Children, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Department of Cardiothoracic Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - David Winlaw
- Heart Centre for Children, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Faculty of Medicine, School of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia *Medical student; currently pursuing MBBS
| | - Richard Chard
- Heart Centre for Children, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Department of Cardiothoracic Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Yishay Orr
- Heart Centre for Children, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Department of Cardiothoracic Surgery, Westmead Hospital, Westmead, New South Wales, Australia
- Faculty of Medicine, School of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia *Medical student; currently pursuing MBBS
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Nathan M. The left atrioventricular valve: The Achilles' heel of incomplete endocardial cushion defects. J Thorac Cardiovasc Surg 2018; 157:1130-1131. [PMID: 30538029 DOI: 10.1016/j.jtcvs.2018.10.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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24
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Martin E, Del Nido PJ, Nathan M. Technical performance scores are predictors of midterm mortality and reinterventions following congenital mitral valve repair. Eur J Cardiothorac Surg 2018; 52:218-224. [PMID: 28398542 DOI: 10.1093/ejcts/ezx074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/25/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The Technical Performance Score (TPS) has been shown to be predictive of postoperative mortality, morbidities and reinterventions following various cardiac procedures in children. We hypothesized that TPS is also a predictor of mitral valve repair outcomes. METHODS A review of patients who underwent mitral valve repair from January 2000 to December 2013 was performed. Primary repair of complete atrioventricular defect was excluded. The scores were determined according to previously published criteria based on the need for reintervention and predischarge echocardiograms: Class 1 (no residua), Class 2 (minor residua) or Class 3 (pacemaker implantation, major residua or reintervention for major residua prior to discharge). Cox proportional hazard models and Kaplan-Meier estimator were used. RESULTS A total of 587 patients underwent mitral repair (median age 2.6 years). Median follow-up duration was 3 years. There were 125 (21.3%) post-discharge mitral reinterventions and freedom from reintervention was 85.2%, 78.2% and 69.4% at 1, 2 and 5 years, respectively. Both TPS Class 2 [hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.4-10.0; P = 0.02] and Class 3 (HR 8.7, 95% CI 3.0-25.1; P < 0.001) were associated with post-discharge reinterventions. There were 31 late deaths/transplantations, and transplant-free survival at 1, 2 and 5 years was 97.8%, 95.3% and 93.2%. TPS 3 was associated with decreased post-discharge transplant-free survival (HR 5.5, 95% CI 1.2-25.0; P = 0.03). Post-discharge mitral reintervention was not associated with increased mortality. CONCLUSIONS The TPS is a strong predictor of midterm mortality and post-discharge mitral reintervention in congenital patients who underwent mitral repair.
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Affiliation(s)
- Elisabeth Martin
- Division of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Université Laval, Quebec City, Quebec, Canada.,Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
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Scanlan AB, Nguyen AV, Ilina A, Lasso A, Cripe L, Jegatheeswaran A, Silvestro E, McGowan FX, Mascio CE, Fuller S, Spray TL, Cohen MS, Fichtinger G, Jolley MA. Comparison of 3D Echocardiogram-Derived 3D Printed Valve Models to Molded Models for Simulated Repair of Pediatric Atrioventricular Valves. Pediatr Cardiol 2018; 39:538-547. [PMID: 29181795 PMCID: PMC5831483 DOI: 10.1007/s00246-017-1785-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/22/2017] [Indexed: 12/20/2022]
Abstract
Mastering the technical skills required to perform pediatric cardiac valve surgery is challenging in part due to limited opportunity for practice. Transformation of 3D echocardiographic (echo) images of congenitally abnormal heart valves to realistic physical models could allow patient-specific simulation of surgical valve repair. We compared materials, processes, and costs for 3D printing and molding of patient-specific models for visualization and surgical simulation of congenitally abnormal heart valves. Pediatric atrioventricular valves (mitral, tricuspid, and common atrioventricular valve) were modeled from transthoracic 3D echo images using semi-automated methods implemented as custom modules in 3D Slicer. Valve models were then both 3D printed in soft materials and molded in silicone using 3D printed "negative" molds. Using pre-defined assessment criteria, valve models were evaluated by congenital cardiac surgeons to determine suitability for simulation. Surgeon assessment indicated that the molded valves had superior material properties for the purposes of simulation compared to directly printed valves (p < 0.01). Patient-specific, 3D echo-derived molded valves are a step toward realistic simulation of complex valve repairs but require more time and labor to create than directly printed models. Patient-specific simulation of valve repair in children using such models may be useful for surgical training and simulation of complex congenital cases.
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Affiliation(s)
- Adam B Scanlan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Alex V Nguyen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Anna Ilina
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, ON, USA
| | - Andras Lasso
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, ON, USA
| | - Linnea Cripe
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Anusha Jegatheeswaran
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth Silvestro
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Francis X McGowan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Meryl S Cohen
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gabor Fichtinger
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, ON, USA
| | - Matthew A Jolley
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Jolley MA, Ghelani SJ, Adar A, Harrild DM. Three-Dimensional Mitral Valve Morphology and Age-Related Trends in Children and Young Adults with Structurally Normal Hearts Using Transthoracic Echocardiography. J Am Soc Echocardiogr 2017; 30:561-571. [PMID: 28391001 DOI: 10.1016/j.echo.2017.01.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND The mitral valve has a complex three-dimensional (3D) morphology that is incompletely described by two-dimensional echocardiography (echo). Three-dimensional echo provides a more robust tool to analyze the mitral valve. The shape of the mitral annulus and leaflets, and differences with age, have not been described by 3D echo in normal children. Our objective was to characterize and quantify the 3D mitral valve morphology in children with normal transthoracic echocardiograms over a broad spectrum of age and to identify differences in valve shape with age. METHODS Three-dimensional midsystolic mitral valve models were constructed in 100 children and young adults with normal echocardiograms using 3D transthoracic images. Annular and leaflet metrics were quantified and regression equations were prepared. Interuser and intrauser variability was measured. RESULTS Two hundred fifty patients, from neonate to young adult, were retrospectively reviewed to obtain 100 evaluable patients (40% evaluable). The annular height to commissural width ratio of the mitral valve ("saddle shape") was preserved across age (median 24.3, IQR 21.8-28.1). Three-dimensional mitral valve area, length, and volume parameters were linearly related to body surface area (P < .001). The ratio of anterior to posterior leaflet length and posterior leaflet angle increased with body surface area (P = .0004 and .002, respectively) suggesting posterior movement of the coaptation line. Two-dimensional lateral annular diameter underestimated 3D lateral annular metrics (P < .001, mean difference 20-22%) but was highly correlated (R > 0.87, P < .001). Interuser and intrauser variability were acceptable. CONCLUSIONS Assessment of 3D mitral valve morphology in children is possible in a modern clinical pediatric echocardiography laboratory using transthoracic images, although further optimization of imaging is needed. The saddle shape of the mitral annulus was preserved across age and size. Most mitral valve parameters increased linearly with patient size. Further investigation is warranted to explore changes in valve morphology in the pediatric population in health and with disease.
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Affiliation(s)
- Matthew A Jolley
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatric Cardiac Anesthesia and Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Adi Adar
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Ilina A, Lasso A, Jolley MA, Wohler B, Nguyen A, Scanlan A, Baum Z, McGowan F, Fichtinger G. Patient-specific pediatric silicone heart valve models based on 3D ultrasound. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2017; 10135. [PMID: 32132766 DOI: 10.1117/12.2255849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
PURPOSE Patient-specific heart and valve models have shown promise as training and planning tools for heart surgery, but physically realistic valve models remain elusive. Available proprietary, simulation-focused heart valve models are generic adult mitral valves and do not allow for patient-specific modeling as may be needed for rare diseases such as congenitally abnormal valves. We propose creating silicone valve models from a 3D-printed plastic mold as a solution that can be adapted to any individual patient and heart valve at a fraction of the cost of direct 3D-printing using soft materials. METHODS Leaflets of a pediatric mitral valve, a tricuspid valve in a patient with hypoplastic left heart syndrome, and a complete atrioventricular canal valve were segmented from ultrasound images. A custom software was developed to automatically generate molds for each valve based on the segmentation. These molds were 3D-printed and used to make silicone valve models. The models were designed with cylindrical rims of different sizes surrounding the leaflets, to show the outline of the valve and add rigidity. Pediatric cardiac surgeons practiced suturing on the models and evaluated them for use as surgical planning and training tools. RESULTS Five out of six surgeons reported that the valve models would be very useful as training tools for cardiac surgery. In this first iteration of valve models, leaflets were felt to be unrealistically thick or stiff compared to real pediatric leaflets. A thin tube rim was preferred for valve flexibility. CONCLUSION The valve models were well received and considered to be valuable and accessible tools for heart valve surgery training. Further improvements will be made based on surgeons' feedback.
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Affiliation(s)
- Anna Ilina
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Canada
| | - Andras Lasso
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Canada
| | | | | | - Alex Nguyen
- The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Adam Scanlan
- The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Zachary Baum
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Canada
| | - Frank McGowan
- The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Gabor Fichtinger
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Canada
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Myers PO, Baird CW, Del Nido PJ, Pigula FA, Lang N, Marx GR, Emani SM. Neonatal Mitral Valve Repair in Biventricular Repair, Single Ventricle Palliation, and Secondary Left Ventricular Recruitment: Indications, Techniques, and Mid-Term Outcomes. Front Surg 2015; 2:59. [PMID: 26618162 PMCID: PMC4639623 DOI: 10.3389/fsurg.2015.00059] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/29/2015] [Indexed: 01/11/2023] Open
Abstract
Objectives Although mitral valve repair is rarely required in neonates, this population is considered to be at high risk for adverse outcomes. The aim of this study was to review the indications for surgery, mechanisms, repair techniques, and mid-term outcomes of neonatal mitral valve repair. Methods The demographic, procedural, and outcome data were obtained for all neonates who underwent mitral valve repair from 2005 to 2012. The primary endpoints included mortality, transplantation, and mitral valve reoperation. Results Twenty patients were included during the study period. Median age at operation was 11 days (range: 3–25). Eleven patients (55%) presented with mitral stenosis, three had regurgitation (15%), and six had mixed mitral disease (30%). Nineteen of 20 patients had mild or less regurgitation on immediate postoperative imaging. During a median follow-up of 5 months (1 month–4.8 years), six patients died at a median of 33 months (7–41 months) from repair and one patient required orthotopic heart transplantation. Six patients required mitral valve reoperation, five for mitral valve re-repair, and one for mitral valve replacement. Freedom from death, transplantation, or mitral valve replacement was 84.2 ± 8.4% at 1 month, 71.3 ± 11% at 6 months, 64.1 ± 12% at 1 year, and 51.3 ± 15% at 2 years and was worse for patients presenting with mitral regurgitation compared to stenosis or mixed mitral valve disease. Conclusion Although mitral valve repair can be performed with acceptable immediate postoperative result, this procedure carries a high burden of late death and mitral valve reoperations.
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Affiliation(s)
- Patrick O Myers
- Cardiac Surgery, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA ; Cardiovascular Surgery, Geneva University Hospitals and School of Medicine , Geneva , Switzerland
| | - Christopher W Baird
- Cardiac Surgery, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
| | - Pedro J Del Nido
- Cardiac Surgery, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
| | - Frank A Pigula
- Cardiac Surgery, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
| | - Nora Lang
- Cardiology, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
| | - Gerald R Marx
- Cardiology, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
| | - Sitaram M Emani
- Cardiac Surgery, Boston Children's Hospital, Harvard Medical School , Boston, MA , USA
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Song IK, Lee JH, Kim EH, Kim HS, Kim JT. Inverted Prosthetic Valve Detected by Transesophageal Echocardiography After Mitral Valve Replacement. J Cardiothorac Vasc Anesth 2015; 29:e78-9. [PMID: 26409921 DOI: 10.1053/j.jvca.2015.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Indexed: 11/11/2022]
Affiliation(s)
- In-Kyung Song
- Department of Anesthesiology and Pain Medicine Seoul National University Hospital Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine Seoul National University Hospital Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine Seoul National University Hospital Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine Seoul National University Hospital Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine Seoul National University Hospital Seoul, Republic of Korea
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Quinonez LG, Del Nido PJ. Valve reconstruction for congenital mitral valve disease. Multimed Man Cardiothorac Surg 2015; 2015:mmv007. [PMID: 26012593 DOI: 10.1093/mmcts/mmv007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/19/2015] [Indexed: 06/04/2023]
Abstract
The surgical treatment of mitral valve disease in children is a challenging problem. Mitral stenosis and regurgitation may occur in isolation or together. Mitral valve repair is almost always preferable to replacement. Mitral valve replacement is not an ideal alternative to repair due to limitations of size, growth, structural valve degeneration, anticoagulation and poor survival. Surgical repair of congenital mitral stenosis must address the multiple levels of obstruction, including resection of the supramitral ring, thinning of leaflets and mobilization of the subvalvular apparatus. Sometimes leaflet augmentation is required. Repair of mitral regurgitation in children may involve simple cleft closures, edge-to-edge repairs, triangular resections and annuloplasties. Techniques used in adults, such as annuloplasty bands or artificial chords, may not be appropriate for children. Overall, an imperfect mitral valve repair may be more acceptable than the negative consequences of a replacement in a child.
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Review of Congenital Mitral Valve Stenosis: Analysis, Repair Techniques and Outcomes. Cardiovasc Eng Technol 2015; 6:167-73. [DOI: 10.1007/s13239-015-0223-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
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Myers PO, del Nido PJ, Bautista-Hernandez V, Marx GR, Emani SM, Pigula FA, Borisuk M, Baird CW. Biventricular repair for common atrioventricular canal defect with parachute left atrioventricular valve. Eur J Cardiothorac Surg 2015; 49:546-51; discussion 551-2. [PMID: 25838456 DOI: 10.1093/ejcts/ezv114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 02/25/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Parachute left atrioventricular (AV) valve can complicate repair of common atrioventricular canal (CAVC), and single-ventricle palliation is sometimes preferred. The goal of this study is to review our single institutional experience in biventricular repair in this patient group. METHODS The demographic, procedural and outcome data were obtained for all children who underwent biventricular repair for complete CAVC with parachute [single left ventricular (LV) papillary muscle] or forme fruste parachute left AV valve (closely spaced LV papillary muscles) from 2001 to 2012. Primary outcomes were survival, freedom from left AV valve stenosis (defined as an inflow gradient ≥7 mmHg and post-capillary pulmonary hypertension) and freedom from left AV valve replacement. RESULTS A total of 24 patients were included (21 parachutes, 3 forme frustes). There was 1 early death (4.2%). At discharge, no patient had more-than-mild regurgitation and 1 had stenosis. During a median follow-up of 3.7 years (IQR 4 months to 5 years), there were 2 late deaths (8.3%), 6 patients (25%) presented significant left AV valve stenosis and 2 patients (8.3%) required valve replacement. Freedom from stenosis was 95 ± 4.9% at 1 year, 83.1 ± 8.9% at 3 years, 64.7 ± 13.5% at 5 years and 51.7 ± 15.8% at 10 years. Complete cleft closure was not associated with a significantly different freedom from left AV valve reoperation (log-rank test, P = 0.89) or significant stenosis (P = 0.47). CONCLUSION Biventricular repair in parachute left AV valve and CAVC is feasible with acceptable mortality and freedom from stenosis. The burden of reoperation remains significant in this patient group.
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Affiliation(s)
- Patrick O Myers
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA Division of Cardiovascular Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pedro J del Nido
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Victor Bautista-Hernandez
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gerald R Marx
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Frank A Pigula
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michele Borisuk
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Baird CW, Myers PO, Borisuk M, Kalish B, Hofferberth S, Nathan M, Emani SM, del Nido PJ. Takedown of cavopulmonary shunt at biventricular repair. J Thorac Cardiovasc Surg 2014; 148:1506-11. [DOI: 10.1016/j.jtcvs.2014.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/08/2014] [Indexed: 12/14/2022]
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Myers PO, Cikirikcioglu M, Kalangos A. Biodegradable materials for surgical management of infective endocarditis: new solution or a dead end street? BMC Surg 2014; 14:48. [PMID: 25087015 PMCID: PMC4131057 DOI: 10.1186/1471-2482-14-48] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 07/24/2014] [Indexed: 01/29/2023] Open
Abstract
Background One third of patients with infective endocarditis will require operative intervention. Given the superiority of valve repair over valve replacement in many indications other than endocarditis, there has been increasing interest and an increasing number of reports of excellent results of valve repair in acute infective endocarditis. The theoretically ideal material for valve repair in this setting is non-permanent, “vanishing” material, not at risk of seeding or colonization. The goal of this contribution is to review currently available data on biodegradable materials for valve repair in infective endocarditis. Discussion Rigorous electronic and manual literature searches were conducted to identify reports of biodegradable materials for valve repair in infective endocarditis. Articles were identified in electronic database searches of Medline, Embase and the Cochrane Library, using a predetermined search strategy. 49 manuscripts were included in the review. Prosthetic materials needed for valve repair can be summarized into annuloplasty rings to remodel the mitral or tricuspid annulus, and patch materials to replace resected valvar tissue. The commercially available biodegradable annuloplasty ring has shown interesting clinical results in a single-center experience; however further data is required for validation and longer follow-up. Unmodified extra-cellular matrix patches, such as small intestinal submucosa, have had promising initial experimental and clinical results in non-infected valve repair, although in valve repair for endocarditis has been reported in only one patient, and concerns have been raised regarding their mechanical stability in an infected field. Summary These evolving biodegradable devices offer the potential for valve repair with degradable materials replaced with autologous tissue, which could further improve the results of valve repair for infective endocarditis. This is an evolving field with promising experimental or initial clinical results, however long-term outcomes are lacking and further data is necessary to validate this theoretically interesting approach to infective endocarditis.
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Affiliation(s)
- Patrick O Myers
- Cardiovascular Surgery, Geneva University Hospitals & Faculty of Medicine, 4 rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland.
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