Ann Thorac Surg 2007;84:2065. doi:10.1016/j.athoracsur.2007.09.024
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Glenn J. Pelletier, MD
Saint Christopher’s Hospital for Children, Erie Ave at Front St, Philadelphia, PA 19134
(Email: gpelleti{at}drexelmed.edu).
Infective endocarditis (IE) in children occurs overwhelmingly in individuals who have surgically treated and untreated structural heart disease such as ventricular septal defect, patent ductus arteriosus, and tetralogy of Fallot. While the incidence of IE in children is low, there is a growing population of children who are at risk after surviving both palliative and corrective operative procedures. Despite the most advanced medical therapy, the mortality for IE in the pediatric literature is reported to be as high as 25 per cent. Recent series of adult patients with mitral valve endocarditis have shown a reduction in morbidity and mortality when early surgical intervention is practiced for intractable heart failure, severe mitral regurgitation, persistent sepsis despite appropriate antimicrobial medications, large vegetations, systemic embolism, or prosthetic valve endocarditis. Further, mitral valve repair appears to have benefits over mitral valve replacement when compared for both overall and event-free survival, early reoperation, recurrent endocarditis, and cerebrovascular events. Delmo Walter and colleagues’ series [1] of eight children treated for IE with mitral valve repair is the first known report of this treatment strategy applied in this age group, and their results are outstanding.
The repair techniques employed by this group including the use of autologous pericardium in place of prosthetic material are particularly advantageous in children. The lack of recurrent endocarditis after nearly 10 years follow up in this study may be due to this practice. Equally important is the overall strategy to avoid fixation of the mitral annulus with a prosthetic ring that has the potential to limit annular growth. Finally, performing mitral valve repairs with autologous tissue instead of replacing the valve with a mechanical prosthesis obviates the need for anticoagulation in a child, and therefore eliminates the cumulative morbidity, expense, and lifestyle accommodations that are inherent with warfarin therapy.
Adopting a vigilant approach to the treatment of mitral valve endocarditis in children is critical to reducing the mortality of this disease. A keen appreciation for ineffective medical management and a readiness for early surgical intervention are key ingredients to better outcomes. Coupled with a mitral valve repair strategy using autologous tissue, such a protocol seems likely to achieve optimal results.
 |
References
|
|---|
- Delmo Walter EM, Musci M, Nagdyman N, Hübler M, Berger F, Hetzer R. Mitral valve repair for infective endocarditis in children Ann Thorac Surg 2007;84:2059-2065.[Abstract/Free Full Text]
Related Article
-
Mitral Valve Repair for Infective Endocarditis in Children
- Eva Maria Delmo Walter, Michele Musci, Nicole Nagdyman, Michael Hübler, Felix Berger, and Roland Hetzer
Ann. Thorac. Surg. 2007 84: 2059-2065.
[Abstract]
[Full Text]
[PDF]
Top
References