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Late left ventricular function after surgery for children with chronic symptomatic mitral regurgitation
U S Krishnan1, W M Gersony, E Berman-Rosenzweig
1Columbia University College of Physicians and Surgeons and the Department of Pediatrics, Babies and Children's Hospital, New York, NY 10032, USA.
Insights
Pediatric mitral regurgitation surgery normalizes left ventricular function long-term. Delaying surgery in children until severe symptoms appear does not increase the risk of ventricular dysfunction, but may increase atrial arrhythmias.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Echocardiography
Background:
- Quantitative echocardiography aids surgical timing in adult mitral regurgitation.
- Pediatric mitral regurgitation surgery is often delayed due to patient size and anticoagulation needs.
- Delayed surgery in children may lead to severe symptoms and potential reoperation.
Purpose of the Study:
- To assess long-term ventricular function after mitral valve surgery in children.
- To identify risk factors for adverse outcomes in pediatric mitral regurgitation surgery.
Main Methods:
- Studied 33 pediatric patients (0.5-19 years) with mitral regurgitation.
- Assessed left ventricular shortening fraction preoperatively and postoperatively.
- Followed patients for a mean of 4.5 years after mitral valvuloplasty or replacement.
Main Results:
- Early postoperative ventricular function was reduced but improved significantly on late follow-up.
- Late left ventricular function normalized in most patients, with only one showing dysfunction.
- Preoperative function did not correlate with early or late postoperative values.
- Duration of mitral insufficiency was associated with atrial arrhythmias.
Conclusions:
- Late left ventricular function normalizes after surgical correction of mitral insufficiency in children.
- Delayed surgery in children with significant mitral regurgitation does not increase the risk of long-term ventricular dysfunction.
- Late atrial arrhythmias are more common in children who undergo delayed surgery.
Background:
The use of quantitative echocardiography has been emphasized in optimizing timing of surgery in adult patients with mitral regurgitation to avoid irreversible left ventricular dysfunction. In contrast, surgery for infants and children is often delayed until the appearance of severe symptoms because of the patient's size and anticoagulation requirements and the possible need for early reoperation. The purpose of this study was to determine long-term ventricular function after mitral valve surgery in symptomatic children and to analyze risk factors for adverse outcome.
Methods And Results:
Thirty-three patients (0.5 to 19 years old) operated on for mitral regurgitation as a single hemodynamically significant lesion were studied. All but 3 had medically refractory symptoms. One patient died during surgery, and 32 were followed for 0.3 to 17.1 years (mean, 4.5 years). The mean preoperative left ventricular shortening fraction was 0.38+/-0.09. Successful mitral valvuloplasty or replacement was documented by long-term normalization of end-diastolic dimensions. Early postoperative shortening fraction was significantly reduced (0.28+/-0.1, P<.01), but it improved to 0.40+/-0.07 (P<.01) on late follow-up, at which time only 1 patient had ventricular dysfunction. Preoperative shortening fractions did not correlate well with early or late postoperative values (r=.18 and r=.31, respectively). Seven of 32 surviving patients had preoperative shortening fractions <0.33 (mean, 0.26+/-0.05) and 25 >0.33 (mean, 0.39+/-0.08). Analysis of these subgroups showed no significant differences between the groups in early or late postoperative function. Duration of mitral insufficiency appeared to be associated with the development of atrial arrhythmias.
Conclusions:
Late left ventricular function normalizes in children after surgical correction of mitral insufficiency. In contrast to adults, delay of surgery in children with significant mitral regurgitation until the onset of severe symptoms does not increase the risk for long-term ventricular dysfunction, although late atrial arrhythmias are more likely to be encountered.