Re-replacement of the atrioventricular valve for the systemic circulation in children

The study aim was to determine whether re-replacement of the systemic atrioventricular (AV) valve can be achieved efficiently in children.

The systemic AV valve was re-replaced in 10 children. Initial replacement was needed for regurgitation in nine cases and congenital mitral stenosis in one case at a mean age of 3.7 +/- 3.1 years (range: 0.7-10.2 years). The initial prosthesis chosen was a mechanical valve in all cases; prosthesis size ranged from 16 mm to 27 mm. Reoperation was indicated at a mean age of 9.7 +/- 3.6 years (range: 3.5-14.8 years) because of non-structural dysfunction in five cases, prosthetic valve endocarditis in two, thrombosed valve in two, and progressive obstruction of the left ventricular outflow tract in one case. Fibrous tissues were extensively resected to enlarge the valvular orifice. A translocation maneuver was employed in five cases.

Re-replacement using a bileaflet mechanical valve was successful, with no operative or late deaths. Up-sizing was feasible in six cases with the initial valve < or = 25 mm, the alternative prosthesis being 2-8 mm (mean 4.5 mm) larger than the initial one. Consecutive echocardiography demonstrated improved peak flow velocity across the AV valve (from 2.3 +/- 0.6 to 1.6 +/- 0.3 m/s). Catheterization showed improved mean pulmonary arterial pressure (from 32 +/- 13 to 21 +/- 3 mmHg). No change was seen in cardiac index (3.4 +/- 0.6 and 3.5 +/- 0.6 l/min/m2) or systemic ventricular ejection fraction (55 +/- 14% and 49 +/- 23%).

Re-replacement of the systemic AV valve can be achieved efficiently, even in children, with up-sizing feasible by appropriate surgical maneuvers.