Mitral Valve Surgery in Infants and Children: Surgical Approach, Predictors and Outcomes in 143 Pediatric Patients
Erin Isaacson1, Camille Lucjak1, William Johnson1, Ziyan Yin1, Tao Wang1, *Ronald Woods1, *James Tweddell2, Viktor Hraska1, Michael E Mitchell3
1Medical College of Wisconsin, Milwaukee, WI;2Cincinnati Children's Hospital, Cincinnati, OH;3Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI
The surgical treatment of mitral disease in the pediatric population continues to be challenging. Managing diversity in patient anatomy, growth, and avoiding the need for long term anticoagulation or re-operation often requires tradeoffs between imperfect solutions. We sought to assess our approach to mitral valve surgery in infants and children, and to identify predictors associated with mortality, re-operation and recurrent mitral disease.
The medical records, echocardiograms, and operative reports of all patients who underwent surgical intervention for mitral valve repair or replacement from January 2000 through April 2016 were reviewed. Patients undergoing repair of AV canal and patients with single ventricle physiology at the time of surgery were excluded. Pre-operative clinical status, mitral valve pathology, surgical indications, and valve function were assessed. Operative and peri-operative outcomes as well as clinical and echocardiographic findings at follow-up were compared. Primary outcomes included death, transplant, mitral valve re-operation, and degree of mitral valve stenosis and regurgitation on follow-up.
143 patients undergoing mitral valve surgery were included for analysis. 64 were infants (< 1 year old), mean age 142 days and weight 5.1kg, and 79 were children (1 to 18 years old), with mean age 8 yrs, weight 24.4kg. 74 were male and 69 were female. Of 143 primary mitral valve operations,133 were valve repairs and 10 were valve replacements (5 infants and 5 children). Infants undergoing mitral valve surgery had a significantly higher rate of defined genetic abnormality compared to children (31.2% vs 8.9%, p=.018) and were more likely to be intubated prior to initial surgery (17.2% vs 0%, p<.001). Degree of preoperative mitral regurgitation and mitral stenosis was similar between the groups. Mean cross-clamp time was longer in infants (97 vs 84 minutes, p=0.04). Median length of stay was longer for infants (15 vs 5 days, p=<0.001), and operative mortality was higher in infants (10.9% vs. 0%, p=0.003). Mean followup was 4.1 years. Freedom from death or transplant, and freedom from reoperation on the mitral valve was worse in infants (p <0.001; and p= 0.028). Infants and children demonstrated parrallel progression of mitral valve pathology over time (see figure).
Infants undergoing mitral valve surgery have more pre-operative risk factors and more complicated operative and post-operative courses compared to children, despite similar degrees of mitral stenosis and regurgitation. Both groups demonstrated progression in mitral valve pathology over time. There is room for improvement and innovation in surgical strategies for mitral valve disease in the pediatric population.
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