Mitral valve replacement in children. Comparative study of pre- and postoperative haemodynamics and left ventricular...

Haemodynamic variables and left ventricular function were studied before and after mitral valve replacement in 44 children age 3 to 17 years (mean 11.9 years). Thirty-nine Starr-Edwards prostheses and five Hancock prostheses were used; postoperative study took place two to six months (mean 3.9 months) after operation. Pulmonary hypertension was present preoperatively in most patients, with mean pulmonary artery pressures of 18 to 75 (mean 46.5 mmHg). Postoperatively there was a pronounced drop in pressure to a mean value of 25.6 mmHg, partially explained by a decrease in pulmonary capillary wedge pressure. Pulmonary arteriolar resistance, however, also decreased conspicuously from an average of 590 dynes s cm-5 m-2 preoperatively to 282 dynes s cm-5 m-2 postoperatively. A return to normal resistance was seen in every case when preoperative resistance did not exceed 650 dynes s cm-5 m-2; above this threshold some degree of pulmonary hypertension often persisted. The residual gradient across the prosthetic valve was slightly higher for the Hancock than for the Starr-Edwards prosthesis (mean 8.7 mmHg, vs mean 6.9 mmHg). The left ventricular end-diastolic volume was much increased before surgery, with a mean value of 190 ml/m2; it decreased conspicuously after operation to 103 ml/m2. The left ventricular ejection fraction ranged from 40% to 76% (mean 57%) before operation; there was no significant change after operation, with values ranging from 40% to 73%. This left ventricular dysfunction is probably the result of myocardial injury caused by a chronic volume overload and the sequelae of rheumatic carditis.