Optimizing long-term outcomes in pediatric mitral valve repair: A focus on posterior leaflet augmentation

To evaluate mid- and long-term outcomes of posterior leaflet augmentation with fresh autologous pericardium for congenital or acquired mitral regurgitation in pediatric populations, and to identify predictors of valve-related reintervention.

A retrospective review was conducted on all patients who underwent mitral valve repair, including posterior leaflet augmentation, at Bambino Gesù Children's Hospital between 2011 and 2024. Patients with atrioventricular septal defects or single-ventricle physiology were excluded. Demographic, operative, and echocardiographic data were analyzed. Freedom from reintervention was estimated using Kaplan-Meier analysis and risk factors were identified by Cox proportional hazards modeling.

Twenty-eight patients (median age, 3.8 years; interquartile range, 0.6-9.2 years; 57% men) underwent posterior leaflet augmentation using fresh autologous pericardium. Congenital mitral dysplasia was the most common etiology (50%), followed by rheumatic disease (29%). Mean preoperative mitral regurgitation grade was 3.9 ± 0.6, decreasing to 1.4 ± 0.5 postoperatively, and remained stable during follow-up (mean residual mitral regurgitation, 1.7 ± 0.7 mm Hg). Mean transmitral gradient increased from 2.5 ± 1.8 mm Hg to 4.2 ± 2.1 mm Hg, remaining stable over time (4.9 ± 2.2 mm Hg at last follow-up). During a median follow-up of 7.7 years (interquartile range, 6.6-10.5 years), 9 patients (32%) required reintervention, all consisting of mitral valve replacement. Freedom from reintervention was 84.9% at 1 year, 75.9% at 5 years, and 54.2% at 10 years. A postoperative mean gradient >5 mm Hg was the only independent predictor of reintervention (hazard ratio, 7.81; 95% CI, 1.9-31.4; P = .004).

Posterior leaflet augmentation with fresh autologous pericardium provides a durable, growth-preserving, and physiologic repair for pediatric mitral valve disease predominantly presenting with severe regurgitation. A postoperative transmitral gradient >5 mm Hg identifies patients at higher risk for late mitral valve replacement, emphasizing the importance of accurate intraoperative tailoring and early echocardiographic follow-up.