Valve replacement in children: A challenge for a whole life

Abstract

Valvular pathology in infants and children poses numerous challenges to the paediatric cardiac surgeon. Without question, valvular repair is the goal of intervention because restoration of valvular anatomy and physiology using native tissue allows for growth and a potentially better long-term outcome. When reconstruction fails or is not feasible, valve replacement becomes inevitable. Which valve for which position is controversial. Homograft and bioprosthetic valves achieve superior haemodynamic results initially but at the cost of accelerated degeneration. Small patient size and the risk of thromboembolism limit the usefulness of mechanical valves, and somatic outgrowth is an universal problem with all available prostheses. The goal of this article is to address valve replacement options for all four valve positions within the paediatric population. We review current literature and our practice to support our preferences. To summarize, a multitude of opinions and surgical experiences exist. Today, the valve choices that seem without controversy are bioprosthetic replacement of the tricuspid valve and Ross or Ross-Konno procedures when necessary for the aortic valve. On the other hand, bioprostheses may be implanted when annular pulmonary diameter is adequate; if not or in case of right ventricular outflow tract discontinuity, it is better to use a pulmonary homograft with the Ross procedure. Otherwise, a valved conduit. Mitral valve replacement remains the most problematic; the mechanical prosthesis must be placed in the annular position, avoiding oversizing. Future advances with tissue-engineered heart valves for all positions and new anticoagulants may change the landscape for valve replacement in the paediatric population.

Clinical Profile and Management in Children with Rheumatic Heart Disease in a Tertiary Cardiac Care Center of Nepal

“…21 Further there is an additional burden of lifelong oral anticoagulants required after valvular replacement therapy along with the complication of valve thrombosis and systemic embolic disasters. 22 However, 40 children of less than 15 years of age had had to undergo valvular repair/replacement surgery as their symptoms despite adequate and aggressive medical therapy. This is probably because these children presented late in the course of the illness with severely deformed valves and significant dilatation of the heart chambers.…”

Reemplazo valvular mitral en edad pediátrica

“…1 Cuando la reconstrucción falla o no es factible el reemplazo valvular es inevitable. 2 El reemplazo valvular mitral es un procedimiento raro en niños, al que se asocian dificultades clínicas y técnicas específicas. 3,4 Actualmente, dicha cirugía representa un procedimiento de bajo riesgo, incluso en pacientes pequeños, menores de dos años de edad, con baja mortalidad operatoria.…”

“…1 Residente de Cirugía Cardiotorácica Pediátrica. 2 Jefe de Laboratorio de Ecocardiografía. 3 Intensivista Cardiovascular.…”

Progress in developing a living human tissue-engineered tri-leaflet heart valve assembled from tissue produced by the self-assembly approach

“…Mechanical valves are another alternative and are currently one of the preferred replacement options as their main advantage is their durability [21,22]. However for pediatric patients, the mechanical valves will eventually need to be replaced as the patient grows.…”