ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Kouichi Hisatomi
Tadashi Isomura
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Hisatomi, K.
Right arrow Articles by Katoh, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Hisatomi, K.
Right arrow Articles by Katoh, H.

Ann Thorac Surg 1996;62:1773-1777
© 1996 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Mitral Valve Repair for Mitral Regurgitation With Ventricular Septal Defect in Children

Kouichi Hisatomi, MD, Tadashi Isomura, MD, Tohru Sato, MD, Kenichi Kosuga, MD, Kiroku Ohishi, MD, Hirohisa Katoh, MD

Second Department of Surgery, Faculty of Medicine, Kagoshima University, Kagoshima; and Second Department of Surgery and Department of Pediatrics, Kurume University Hospital, Fukuoka, Japan

Accepted for publication June 22, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background. We examined the results of intermediate and long-term follow-up of 25 patients aged 3 months to 11 years (mean, 2.6 ± 2.3 years) who initially underwent conservative mitral valve repair for mitral regurgitation associated with ventricular septal defect between April 1973 and March 1991.

Methods. The preoperative degree of mitral regurgitation was 2+ in 3, 3+ in 17, and 4+ in 5 patients, and the major causes of mitral regurgitation were annular dilatation and prolapse of the anterior leaflet. Annuloplasty was performed in all except 2 patients, suturing of the cleft was done in 3 patients, and posterior mitral leaflet advancement was done in 2 patients. In addition, the papillary muscle was incised and adhesive chordae were removed in 1 patient, and adhesive fused chordae were detached from a leaflet in 1 other patient.

Results. There were no early deaths. Two patients with residual mitral regurgitation with or without mitral stenosis underwent reoperation for mitral valve replacement 2 months and 6 years after the mitral repair, respectively. Late death occurred in 2 patients, and the actuarial survival rate was 92.0% at 15 years after operation. The freedom from reoperation was 91.3% at both 10 and 15 years after the initial operation. Postoperative color Doppler flow imaging was performed in 22 of the 23 survivors, and results showed no mitral regurgitation in 4, mild regurgitation in 14, and moderate regurgitation in 4 patients. Four patients presently have mitral stenosis, with a mean transmitral pressure gradient greater than 10 mm Hg. The residual lesion of moderate mitral regurgitation with or without mitral stenosis developed in 6 of 11 patients in whom bilateral mitral annuloplasty was applied after the initial operation. Nineteen of the 22 survivors without reoperation were in New York Heart Association class I, and 3 were in class II.

Conclusions. Clinical improvement was observed after conservative mitral repair in most pediatric patients with ventricular septal defect. However, careful follow-up for growth potential still appears to be needed to detect changes in mitral regurgitation and the development of mitral stenosis after valve repair, especially after bilateral annuloplasty.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Congenital mitral regurgitation (MR) is usually associated with other cardiac anomalies, and isolated MR is rarely seen [1–4]. For infants and young children in particular, the operative technique for repair of MR varies according to the type of mitral valvular lesion, and whether regurgitation will recur in the postoperative period is sometimes not predictable [1, 5–7]. In this study, we describe the intermediate and long-term results of conservative mitral valve repair for MR associated with ventricular septal defect (VSD) in 25 children and discuss the operative technique.


   Patients and Methods
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Between April 1973 and March 1991, 25 of 671 children with VSD initially underwent conservative mitral valve repair. The age at operation for mitral valve repair ranged from 3 months to 11 years (mean, 2.6 ± 2.3 years). The indication for operation was congestive heart failure associated with pulmonary hypertension in most cases. Three of the 12 patients less than 2 years of age required mechanical ventilation preoperatively. Cardiac catheterization was performed in all patients, and the ratio of right to left ventricular pressures ranged from 0.4 to 1.0. The preoperative New York Heart Association classification was II in 5, III in 16, and IV in 4 patients. The degree of MR followed by the criteria of Sellers and associates [8] was 2+ in 3, 3+ in 17, and 4+ in 5 patients. Two patients had exhibited mild MR (1+) on angiograms before operation and had received closure of the VSD alone as an initial operation; they then underwent mitral valve repair 2 and 4 years, respectively, after the first operation. Other associated anomalies were patent ductus arteriosus in 2 patients and coarctation of the aorta in 1 patient. Patent ductus arteriosus was ligated simultaneously at the initial operation, and the coarctation of the aorta was reconstructed with a subclavian arterial flap 2 months before the intracardiac repair. Two patients who underwent primary mitral valve replacement (MVR) with 23-mm St. Jude Medical prostheses during the study period were excluded.

Ascending aortic and bicaval cannulation was used for all operations. Intermittent aortic cross-clamping was used before 1978; subsequently, induction of cardiac arrest with crystalloid cardioplegia was used for myocardial protection. Mitral valve repair was performed directly through the left atrium on the right side in 19 and through the atrial septum in 6 patients. Reduction of the annular dilatation followed the criteria of Rowlatt and associates [9]. The VSD was located at the conus in 2 patients and in the perimembranous region in 23. The operative findings at the mitral valve were annular dilatation in 23 patients; other lesions included prolapse of the anterior leaflet in 11, hypoplasia of the posterior leaflet in 3, cleft of the posterior leaflet in 3, chordal shortening due to adhesion to the posterior leaflet in 2, and fused papillary muscle in 1. The operative techniques used to repair MR and the late follow-up results of MR are shown in Table 1Go. Asymmetric annuloplasty using the method of Kay and associates [5] and Reed and colleagues [6] was performed in all except 2 patients. The cleft was sutured with 5-0 nylon in 3 patients, and advancement of the posterior mitral leaflet with autologous pericardium was done in 2 patients. To increase the mobility of the mitral leaflet, we incised the papillary muscle and removed adhesive chordae in 1 patient, and detached adhesive chordae from a leaflet in another. When coaptation of the mitral leaflet after asymmetric annuloplasty on one side did not improve the problem sufficiently, additional annuloplasty was performed on the other side, or suturing of the valve at the level of the same commissure was added.


View this table:
[in this window]
[in a new window]
  		Table 1. . Operative Findings and Results
 
During the follow-up period, the success of repair of MR was judged using echocardiography and postoperative angiography. The patients were followed up carefully by pediatricians, and reoperation for the mitral valve was considered when residual MR or mitral stenosis (MS) was found and when symptoms resulted from deterioration of the mitral lesion. Postoperative angiography was performed in 21 patients, including 2 patients who underwent reoperation. All survivors were examined with Doppler color flow mapping between November 1994 and June 1995 for echocardiographic observation of the repaired mitral area and to determine the degree of MR late in the follow-up period. The resultant image was traced, measured for the severity of MR, and classified into one of three categories-mild, moderate, or severe-using the classification described by Miyatake and associates [10].

Actuarial survival rates and cumulative freedom from reoperation were calculated with the Kaplan-Meier method.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
There were no early deaths after initial repair of the mitral valve. Two patients subsequently underwent reoperation; the diagnosis at reoperation was severe MR in 1 patient and combined MS and MR in the other. One patient aged 1 year and 11 months underwent mitral annuloplasty of the unilateral commissure and detachment of the fused chordae of the anterior mitral leaflet in addition to closure of a VSD. Postoperatively, he exhibited residual MR and required mechanical ventilation for 2 months after the initial operation. He then underwent MVR with a 23-mm St. Jude Medical (St. Paul, MN) prosthesis at the age of 2 years and 1 month. However, 1 year after discharge from the hospital, he required a third operation because of a thrombosed valve; he died 3 days after the operation. A 5-year-old girl had closure of VSD and mitral leaflet advancement for the hypoplastic posterior mitral leaflet. Her course was uneventful for 3 years after the operation; however, she started to complain of palpitations at the age of 8 years. Her mitral valve became stenotic with mild regurgitation. She was treated medically, but finally had reoperation for MVR at the age of 11 years. The findings at reoperation showed thickening and calcification of the posterior mitral leaflet, which had had mitral leaflet advancement, and the mitral orifice was 1.5 cm2 with a thickened anterior leaflet.

Late death after initial mitral valve repair occurred in 1 boy who underwent asymmetric mitral annuloplasty at 4 months of age. He had an uneventful clinical course for 3 months after the initial operation, although he had moderate residual MR. However, myocarditis developed after persistent fever of unknown origin, and he died of cardiac failure 1 year after the operation.

Postoperative color Doppler flow imaging was performed an average of 12 years after the operation in 22 of the 23 survivors, and showed no MR in 4 patients, mild MR in 14, and moderate MR in 4. The mitral annuloplasty was performed unilaterally in 12 children and bilaterally in 11 children. In this late follow-up study, the residual lesion of moderate MR with or without MS developed in 6 of 11 patients in whom bilateral mitral annuloplasty was applied after the initial operation. Four patients exhibited MS with a mean transmitral pressure gradient greater than 10 mm Hg. Echocardiogram showed the area of the mitral orifice to be between 1.5 and 2.0 cm2, and the leaflets were thickened. One of the patients is being followed carefully to determine the timing of reoperation.

The actuarial survival rate for the total group of patients was 92.0% at 15 years (Fig 1AGo), and the freedom from reoperation was 95.8% at 5 years and 91.3% at both 10 and 15 years after operation (Fig 1BGo). The cumulative follow-up was 300.1 patient-years, and varied from 4 to 22 years after the initial operation. Nineteen of the 22 survivors without reoperation were in New York Heart Association class I, and 3 were in class II.




View larger version (24K):
[in this window]
[in a new window]
  		Fig 1. . (A) Actuarial survival curve. (B) Freedom from reoperation.

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Numerous studies have been made of congenital MR in the pediatric age group. Repair of mitral valve lesions has remained a therapeutic challenge because conservative valve repair in children has important effects on growth potential [3, 4, 7, 11–13], and it has become apparent that bioprostheses implanted in children develop severe tissue calcification [14]. In the studied patients with VSD, annular dilatation was the major cause of MR, as also reported by Davachi and associates [15]. The valve leaflets themselves showed no important pathologic changes and had good mobility, but slight thickening. The mitral leaflets therefore appeared to be flexible. We performed an annuloplasty, as originally reported by Kay and associates [5] and following the criteria described by Rowlatt and associates [9], in most of the children in our study as a conservative mitral valve repair for MR. This method of repair was effective, showing no appreciable residual MR in 18 patients. However, in 4 of 11 patients who underwent bilateral annuloplasty, substantial MS developed with a transmitral pressure gradient of more above 10 mm Hg on echocardiography in the late follow-up period. Therefore, we consider that bilateral mitral annuloplasty and suture of commissures may cause MS because of the pathologic change of the mitral leaflet in the late period. Retrospectively, based on the residual mitral lesions and operative procedures, we also consider that mitral repair may not be necessary for mild MR associated with VSD. In children with moderate to severe MR, unilateral annuloplasty may be the first choice of operative procedure when subvalvular lesions are not found.

Choosing the method of operation required for patients with an abnormal subvalvular apparatus appears to be complicated. For 1 such patient with abnormal adhesive chordae to the anterior mitral leaflet on the side of the anterolateral commissure, the adhesion was detached and annuloplasty was performed simultaneously at 1 year and 11 months of age. The patient could not be weaned from the mechanical ventilator because of residual MR and hemolysis, and finally underwent MVR with a St. Jude Medical prosthesis. However, he suddenly experienced heart failure from a thrombosed valve and received a third operation with repeated MVR at the age of 3 years, but died 3 days after this operation. Mechanical valve failure due to thromboembolism, as occurred in this case, or pannus formation is sometimes reported as a serious complication of prosthetic valve replacement in children [16–18]. We attempted conservative mitral valve repair for MR; however, MR associated with subvalvular lesions including chordal abnormalities seemed to be difficult to repair conservatively. Therefore, we initially performed MVR in 2 patients with complicated subvalvular lesions during the study period despite our own experience with severe typical complications after MVR in children. On the other hand, Carpentier and associates [1, 12] cited the importance of appropriate repair for individual lesions of the mitral apparatus, and obtained good clinical results with the use of mitral rings for varied mitral valve anomalies. In contrast, Stellin and colleagues [4], reporting their experience with 30 patients in the pediatric age group with malformed mitral valves, used the ring for 5 patients, and they suspected that scar tissue caused by the sutures and the ring itself might limit proper annulus growth and leaflet motion, on the basis of their findings at reoperation in 2 patients. Unfortunately, we cannot discuss whether the ring is useful for MR in pediatric patients, because the mitral ring was not used in any children in our series. However, our results suggest that mitral annuloplasty is reliable even late in the postoperative period for most patients of this kind in the pediatric population. Most of the studied children showed annular dilatation, and we analyzed the anatomic findings based on our operative notes. The mitral annular dilatation seemed to be caused by cardiac dilatation due to the shunt through the VSD, and the annular dilatation might cause the incompetence of the mitral leaflets in children with VSD.

Two patients underwent mitral leaflet advancement with autologous pericardium because of severe shortening of the posterior leaflet with no subvalvular lesion. One of these patients required MVR 6 years after the initial operation because of combined MS and MR, and the other exhibited moderate MR on echocardiographic examination from prolapse of the anterior mitral leaflet. In 1992, we reported the operative technique of mitral leaflet advancement and the postoperative results for patients with solitary MS or MR. Our results suggested that the repaired valve tended to be stenotic late in the postoperative period [19]. This study showed that the use of mitral leaflet advancement necessitates careful medical follow-up.

In the present study, 2 patients suffered from gradual deterioration of MR after primary repair of the VSD, and they underwent mitral valve repair 2 and 4 years, respectively, after the initial closure of VSD. In both patients, cleft of the posterior mitral valve was found at mitral valve repair, and suture of the leaflets was not performed at the initial operation. These findings suggest that suture of the mitral cleft may be needed in such patients at the initial operation even though MR is not substantial.

The actuarial rate of freedom from reoperation was 91.3% at 10 years, and clinical improvement was observed after conservative mitral repair in most patients with VSD. Our findings suggest that conservative repair of MR in these patients does not usually require the use of prosthetic material for dilatation of the mitral annulus, as the MR is thought to be caused by cardiac dilatation due to left-to-right ventricular shunt formation. However, careful follow-up still appears to be needed, especially for children with bilateral annuloplasty or suturing of the mitral commissure, to detect changes in mitral valve movement after valve repair that may affect their growth potential.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Hisatomi, Second Department of Surgery, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890, Japan.


   References
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Carpentier A, Branchini B, Cour JC, et al. Congenital malformations of the mitral valve in children. Pathology and surgical treatment. J Thorac Cardiovasc Surg 1976;72:854–66.[Abstract]
  2. Coles JG, Williams WG, Watanabe T, et al. Surgical experience with reparative techniques in patients with congenital mitral valvular anomalies. Circulation 1987;76(Suppl 3):117–22.
  3. Okita Y, Miki S, Kusuhara K, et al. Early and late results of reconstructive operation for congenital mitral regurgitation in pediatric age group. J Thorac Cardiovasc Surg 1988;96:294–8.[Abstract]
  4. Stellin G, Bortolotti U, Mazzucco A, et al. Repair of congenitally malformed mitral valve in children. J Thorac Cardiovasc Surg 1988;95:480–5.[Abstract]
  5. Kay JH, Egerton WS, Zubiate P. The surgical treatment of mitral insufficiency and combined mitral stenosis and insufficiency with use of the heart-lung machine. Surgery 1961;50:67–75.[Medline]
  6. Reed GE, Tice DA, Clauss RH. Asymmetric exaggerated mitral annuloplasty: repair of mitral insufficiency with hemodynamic predictability. J Thorac Cardiovasc Surg 1965;49:752–61.
  7. Aharon AS, Laks H, Drinkwater DC, et al. Early and late results of mitral valve repair in children. J Thorac Cardiovasc Surg 1994;107:1262–71.[Abstract/Free Full Text]
  8. Sellers RD, Levy MJ, Amplatz K, Lillehei CW. Left retrograde cardioangiography in acquired cardiac disease. Technic, indications and interpretations in 700 cases. Am J Cardiol 1964;14:437–47.[Medline]
  9. Rowlatt UF, Rimoldi HJA, Lev M. The quantitative anatomy of the normal child's heart. Pediatr Clin North Am 1963;10:499–519.
  10. Miyatake K, Izumi S, Okamoto M, et al. Semiquantitative grading of severity of mitral regurgitation by real-time two-dimensional Doppler flow imaging technique. J Am Coll Cardiol 1986;7:82–8.[Abstract]
  11. Kahn DR, Stern AM, Sigmann JM, Kirsh MM, Lennox S, Sloan H. Long-term results of valvuloplasty for mitral insufficiency in children. J Thorac Cardiovasc Surg 1967;53:1–6.[Medline]
  12. Carpentier A, Chauvaud S, Fabiani JN, et al. Reconstructive surgery of mitral valve incompetence. Ten-year appraisal. J Thorac Cardiovasc Surg 1980;79:338–48.[Abstract]
  13. Sousa Uva M, Galletti L, Gayet FL, et al. Surgery for congenital mitral valve disease in the first year of life. J Thorac Cardiovasc Surg 1995;109:164–76.[Abstract/Free Full Text]
  14. Rocchini AP, Weesner KM, Heidelberger K, Keren D, Behrendt D, Rosenthal A. Porcine xenograft valve failure in children: an immunologic response. Circulation 1981;64(Suppl 2):162–71.
  15. Davachi F, Moller JH, Edwards JE. Disease of the mitral valve in infancy: an anatomic analysis of 55 cases. Circulation 1971;43:565–79.[Abstract/Free Full Text]
  16. McGrath LB, Gonzalez-Lavin L, Eldredge WJ, Colombi M, Restrepo D. Thromboembolic and other events following valve replacement in a pediatric population treated with antiplatelet agents. Ann Thorac Surg 1987;43:285–7.[Abstract]
  17. Kadoba K, Jonas RA, Mayer JE, Castaneda AR. Mitral valve replacement in the first year of life. J Thorac Cardiovasc Surg 1990;100:762–8.[Abstract]
  18. Harada Y, Imai Y, Kurosawa H, Ishihara K, Kawada M, Fukuchi S. Ten-year follow-up after valve replacement with the St. Jude Medical prosthesis in children. J Thorac Cardiovasc Surg 1990;100:175–80.[Abstract]
  19. Hisatomi K, Isomura T, Hirano A, et al. Long term follow-up results after reconstruction of the mitral valve by leaflet advancement. Ann Thorac Surg 1992;54:271–5.[Abstract]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
T. Sugita, Y. Ueda, M. Matsumoto, H. Ogino, J.-i. Nishizawa, and K. Matsuyama
Early and late results of partial plication annuloplasty for congenital mitral insufficiency
J. Thorac. Cardiovasc. Surg., August 1, 2001; 122(2): 229 - 233.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
C.-K. Ng, J. Nesser, C. Punzengruber, O. Pachinger, J. Auer, H. Franke, and P. Hartl
Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology
Ann. Thorac. Surg., January 1, 2001; 71(1): 78 - 85.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
H. Ohno, Y. Imai, M. Terada, and T. Hiramatsu
The long-term results of commissure plication annuloplasty for congenital mitral insufficiency
Ann. Thorac. Surg., August 1, 1999; 68(2): 537 - 541.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
S. Chauvaud, J. F. Fuzellier, R. Houel, A. Berrebi, S. Mihaileanu, and A. Carpentier
Reconstructive surgery in congenital mitral valve insufficiency (Carpentier’s techniques): Long-term results
J. Thorac. Cardiovasc. Surg., January 1, 1998; 115(1): 84 - 93.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Kouichi Hisatomi
Tadashi Isomura
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Hisatomi, K.
Right arrow Articles by Katoh, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Hisatomi, K.
Right arrow Articles by Katoh, H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS