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Valve replacement in children: guidelines for selection of prosthesis and timing of surgical intervention
M N Ilbawi1, F S Idriss, S Y DeLeon
1Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, Chicago, IL 60614.
Insights
Pediatric heart valve replacement improves functional class in most patients. Early surgery significantly enhances ventricular ejection fraction, while delayed surgery shows no improvement.
Area of Science:
- Cardiology
- Pediatric Cardiac Surgery
- Biomaterials Science
Background:
- Congenital heart defects often necessitate valve replacement in pediatric patients.
- Choosing the appropriate prosthetic valve and timing of implantation are critical for long-term outcomes.
Purpose of the Study:
- To evaluate the outcomes of primary valve implantations in a pediatric population.
- To assess the impact of valve type, position, and timing of surgery on patient outcomes.
Main Methods:
- Retrospective analysis of 162 primary valve implantations in 159 pediatric patients (3 months to 18 years).
- Valves used included porcine, St. Jude Medical, and Björk-Shiley prostheses.
- Analysis of valve position (aortic, mitral, pulmonary, tricuspid) and anticoagulation strategies.
Main Results:
- Hospital mortality was 6%. Functional class improved in 62% of patients post-operatively.
- Thromboembolic complications were higher with St. Jude Medical valves in the right-sided circulation (57%) compared to the left-sided (12%).
- Bacterial endocarditis occurred in 3 patients, all with porcine valves. Early valve replacement (<2 years) improved ejection fraction (p<0.05), unlike delayed replacement.
Conclusions:
- Primary valve replacement in pediatric patients can lead to significant functional improvement.
- Valve type and position influence complication rates, with specific considerations for St. Jude Medical valves.
- Timely surgical intervention is crucial for optimizing ventricular function and long-term outcomes in pediatric heart valve disease.
Abstract:
One hundred fifty-nine patients ranging from 3 months to 18 years old (mean, 8.1 +/- 3.7 years) underwent 162 primary valve implantations. A porcine valve was used in 104 patients, a St. Jude Medical valve in 40, and a Björk-Shiley valve in 18. The valve replaced was the aortic in 25 patients, the mitral (systemic atrioventricular [AV] valve) in 43, the pulmonary in 71, and the tricuspid (pulmonary AV valve) in 23. Hospital mortality was 6%. Patients with a Björk-Shiley valve received warfarin sodium anticoagulation, and those with a St. Jude Medical valve were given salicylates and dipyridamole. Follow-up is available on all patients 0.6 to 12 years postoperatively (mean, 6.3 +/- 2.6 years). New York Heart Association Functional Class improved in 62% and remained unchanged in 38% of the patients. Thromboembolic complications occurred in only 8 (57%) of 14 patients with a St. Jude Medical valve in the right (pulmonary) side and in 3 (12%) of 26 with the valve in the left (systemic) side of the circulation. Bacterial endocarditis developed in 3 patients, all with porcine valves. Early valve replacement, less than 2 years after detection of hemodynamic deterioration, resulted in improvement in the ventricular ejection fraction in 25 of 29 patients (from 81 +/- 14% to 90 +/- 12% of normal; p less than 0.05). In contrast, the ejection fraction remained abnormal in all 22 patients with delayed valve insertion (more than 2 years) (81 +/- 16% of normal preoperatively and 80 +/- 10% of normal following operation; p = not significant).