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J Thorac Cardiovasc Surg 2008;136:954-961
© 2008 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Mitral valve replacement in infants and children 5 years of age or younger: Evolution in practice and outcome over three decades with a focus on supra-annular prosthesis implantation

^a Department of Cardiology, Children's Hospital, Boston, Mass
^b Department of Cardiac Surgery, Children's Hospital, Boston, Mass
^c Department of Pediatrics, Harvard Medical School, Boston, Mass
^d Department of Surgery, Harvard Medical School, Boston, Mass

Received for publication October 19, 2007; revisions received December 11, 2007; accepted for publication December 14, 2007.

^_* Address for reprints: Doff B. McElhinney, MD, Department of Cardiology, Children's Hospital, 300 Longwood Ave, Boston, MA 02115. (Email: doff.mcelhinney{at}cardio.chboston.org).

Objective: Successful mitral valve replacement in young children is limited by the lack of small prosthetic valves. Supra-annular prosthesis implantation can facilitate mitral valve replacement with a larger prosthesis in children with a small annulus, but little is known about its effect on the outcomes of mitral valve replacement in young children.

Methods: One hundred eighteen children underwent mitral valve replacement at 5 years of age or younger from 1976–2006. Mitral valve replacement was supra-annular in 37 (32%) patients.

Results: Survival was 74% ± 4% at 1 year and 56% ± 5% at 10 years but improved over time (10-year survival of 83% ± 7% from 1994–2006). Factors associated with worse survival included earlier mitral valve replacement date, age less than 1 year, complete atrioventricular canal, and additional procedures at mitral valve replacement, but not supra-annular mitral valve replacement. As survival improved during our more recent experience, the risks of supra-annular mitral valve replacement became apparent; survival was worse among patients with a supra-annular prosthesis after 1991. A pacemaker was placed in 18 (15%) patients within 1 month of mitral valve replacement and was less likely in patients who had undergone supra-annular mitral valve replacement. Among early survivors, freedom from redo mitral valve replacement was 72% ± 5% at 5 years and 45% ± 7% at 10 years. Twenty-one patients with a supra-annular prosthesis underwent redo mitral valve replacement. The second prosthesis was annular in 15 of these patients and upsized in all but 1, but 5 required pacemaker placement for heart block.

Conclusions: Supra-annular mitral valve replacement was associated with worse survival than annular mitral valve replacement in our recent experience. Patients with supra-annular mitral valve replacement were less likely to have operative complete heart block but remained at risk when the prosthesis was subsequently replaced.