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Fate of left-sided cardiac bioprosthesis valves in children
Insights
Porcine bioprosthetic valves (BPVs) showed a high failure rate in pediatric patients, with 94% requiring reoperation within six years due to calcification and leaflet dysfunction. Early replacement is crucial to avoid catastrophic failure and reduce mortality.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Biomaterials Science
Background:
- Anticoagulation and thromboembolic events are significant concerns in pediatric patients requiring valve replacement.
- Porcine bioprosthetic valves (BPVs) were explored as an alternative to minimize these risks.
Purpose of the Study:
- To evaluate the long-term durability and safety of BPVs in pediatric patients undergoing aortic and mitral valve replacement.
Main Methods:
- A retrospective analysis of 18 BPVs implanted in 17 pediatric patients (ages 7-18) between 1975 and 1980.
- Assessment of valve function, complications, and reoperation rates over a mean follow-up of 4.2 years for aortic and 3.1 years for mitral positions.
Main Results:
- High reoperation rates: 91% for aortic (10/11) and 86% for mitral (6/7) BPVs within 6 years.
- Common failure modes included severe calcification, leaflet immobility, stenosis, and regurgitation.
- Catastrophic hemodynamic deterioration occurred in 9 patients, with emergency replacement carrying a 33% mortality rate.
Conclusions:
- BPVs demonstrate a high failure rate (94% within 6 years) in the pediatric population, irrespective of position.
- The study strongly recommends against using BPVs in pediatric aortic or mitral positions due to risks of calcification and catastrophic failure.
- Early elective valve replacement is advised to mitigate the higher mortality associated with emergency surgeries.
Abstract:
To avoid anticoagulation and minimize thromboembolic phenomena, between 1975 and 1980 we used 18 porcine bioprosthetic valves (BPVs) to replace 11 aortic and seven mitral valves in 17 children ranging from 7 to 18 years of age (mean, 8.2 years). Ten BPVs (91%) in the aortic position had to be replaced one to six years (mean, 4.2 years) after insertion. Nine of these valves developed severe calcification with leaflet immobility and severe stenosis. The tenth valve became insufficient with a disrupted cusp. Six (86%) of seven BPVs inserted in the mitral position required replacement two to four years (mean, 3.1 years) after insertion. Massive mitral regurgitation developed in three, while in the other three mitral stenosis was prominent. All explanted BPVs exhibited calcification with disruption and loss of mobility of the leaflets. Hemodynamic deterioration often occurred catastrophically, with nine patients requiring emergency valve replacement. Elective valve replacement carried no hospital mortality, whereas emergency valve replacement carried a 33% mortality. The BPV failure rate of 94% within six years leads us to recommend against the use of biologic valves in the pediatric age group in the aortic or mitral position. Bioprosthetic valve failure may occur catastrophically and replacement should be carried out early to avoid the higher operative mortality associated with emergency surgery.