Mayr B, Vitanova K, Burri M, Lang N, Goppel G, Voss B, Lange R, Cleuziou J.Ann Thorac Surg. 2020 Dec;110(6):2082-2087. doi: 10.1016/j.athoracsur.2020.02.057. Epub 2020 Mar 30.PMID: 32240647
Take Home Message:
- Mitral valve conditions requiring surgical management before the age of 10 years are rare.
- Mortality associated with surgical management of these patients is not small.
- Even if the need for reoperation and valvular replacement is relatively high, most patients still benefit from surgical repair and attempting so is worth it.
Commentary from Dr. Frederic Jacques (Quebec City, QC, Canada), chief section editor of Congenital Heart Surgery Journal Watch:
In the December 2020 issue of Annals of Thoracic Surgery, Mayr et al. report on 50 patients who had surgical repair of their mitral valve before the age of 10 years from 1975 to 2017. Forty patients had congenital problems, while 10 other patients had acquired disease. The authors specifically looked at survival and cumulative incidence of reoperation. The median age at surgical repair was 1.2 years and 1.9 years for congenital and acquired conditions, respectively. Most patients had regurgitation. The mortality for congenital conditions was significant with an immediate operative mortality of 5% and a late mortality of another 10%. No death occurred for acquired problems. Among congenital patients, those experiencing regurgitation had a better outcome, compared to stenosis. At a 6-years follow-up, congenital patients had close to 40% need for reoperation. Ultimately, 10% of patients with initial repair required a synthetic prosthesis. Among the 20% who required a second surgical repair of the mitral valve, 50% ended up with a prosthesis.
This paper reminds us how rare and difficult to deal with are mitral valve problems in children before the age of 10. It shows how risky are these operations, however it is important to acknowledge that valvular surgical repair techniques have significantly changed (likely improved) over the course of the study period. Even though the risk of mortality, the need for reoperation and the need for prosthetic valvular replacement is not dismal, it is important to realize that 90% of these patients can be repaired with a sustainable result. Looking at this paper, pediatric cardiologists and surgeons should be encouraged to make every effort to keep the native valve whenever possible. Expectations of repair should also acknowledge how difficult this problem is, especially for congenital patients. The development of better surgical prosthesis both biological (see Emani et al.) and mechanical (see Ijsselhof et al., Annals of Thoracic Surgery, December 2020) will also improve the overall outcomes for these challenging patients.