ORIGINAL ARTICLE

The early and mid-term results of mitral valve repair for mitralregurgitation in children

Zhaolei Jiang • Ju Mei • Fangbao Ding •

Chunrong Bao • Jiaquan Zhu • Min Tang •

Nan Ma • Jianbing Huang • Saie Shen

Received: 2 May 2013 / Accepted: 5 November 2013

� Springer Japan 2013

Abstract

Purpose To review the surgical techniques and mid-term

results of mitral valve repair in children with moderate or

severe mitral regurgitation (MR).

Methods One hundred and seven children with moderate

or severe MR, aged 19.6 ± 8.5 months, were enrolled in

this study. The surgical techniques used for mitral valve

repair varied according to the mitral valve morphology,

and included annuloplasty, annuloplasty ring, cleft closure,

reconstruction of the posterior leaflet, etc. The concomitant

cardiac anomalies were treated simultaneously. The results

of repair were evaluated by transesophageal echocardiog-

raphy performed during the operation and by serial trans-

thoracic echocardiography performed during the follow-up.

Results One hundred and six cases had no more than mild

regurgitation intraoperatively, whereas only one case had

moderate regurgitation. This patient underwent redo repair

immediately, and the subsequent regurgitation was trivial.

The in-hospital mortality rate was 0.9 % (1/107). The

average follow-up was 46.5 ± 8.2 months. One patient

died of heart failure 10 months postoperatively. The free-

dom from moderate or severe regurgitation after mitral

valve repair was 92.3 ± 3.3 %.

Conclusion Pediatric patients with moderate or severe

MR require early surgical treatment. The early and mid-

term results of mitral valve repair in pediatric patients were

satisfactory.

Keywords Mitral regurgitation � Mitral valve repair �Children

Introduction

Mitral regurgitation (MR) is a common cardiac disease that

occurs mainly due to degenerative valve disease, ischemic

heart disease, rheumatic heart disease, congenital heart

disease, infective endocarditis and Marfan comprehensive

symptom in adults [1–4]. However, pediatric MR is rare,

complex and frequently associated with other congenital

cardiac abnormalities [5–8]. Mitral valve surgery (mitral

valve repair and mitral valve replacement) can alleviate the

clinical symptoms and prevent ventricular dilatation and

heart failure, especially for patients with moderate or

severe MR [9]. Since mitral valve replacement is associ-

ated with a high mortality rate, high reoperation rate and

issues with anticoagulation, mitral valve repair has been

considered to be the preferred method for treating MR in

pediatric patients [10, 11].

Currently, mitral valve repair has achieved satisfactory

results in adults [1, 3]. However, mitral valve repair

remains a challenge in pediatric patients, because the

pathology of MR varies and the mitral valve apparatus is

still growing in children [12, 13]. Some additional diffi-

culties still exist in pediatric mitral valve repair [14]. For

example, the pediatric valve tissue is fragile. And the

spectrum of lesions is wide, including annular dilatation,

leaflet clefts, leaflet defects, leaflet prolapsed, etc. [6, 10].

Z. Jiang � J. Mei (&) � F. Ding � C. Bao � J. Zhu � M. Tang �N. Ma � J. Huang

Department of Cardiothoracic Surgery, Xinhua Hospital,

Shanghai Jiaotong University School of Medicine,

1665 Kongjiang Road, Shanghai 200092, China

e-mail: ju_mei63@126.com

S. Shen

Department of Anesthesiology, Xinhua Hospital,

Shanghai Jiaotong University School of Medicine,

Shanghai 200092, China

123

Surg Today

DOI 10.1007/s00595-013-0816-x

In addition, the surgical exposure is limited. Since children

are still growing, some repair techniques are not applicable

or routinely used in pediatric patients, such as a continuous

annuloplasty ring, triangular resection of the anterior mitral

leaflet and chordal replacement. At present, only a few of

studies with a small sample of patients related to pediatric

mitral valve repair have been reported [12, 13, 15, 16].

In this study, we aimed to share our experience with

mitral valve repair for MR in children. We retrospectively

analyzed 107 pediatric cases of moderate or severe MR

who had undergone mitral valve repair, and observed the

early and mid-term outcomes of the repair.

Materials and methods

Patients

We retrospectively analyzed the pediatric patients with

moderate or severe MR who had undergone mitral valve

repair from 2005 to 2012 in Shanghai Xinhua hospital,

which was affiliated with Shanghai Jiaotong University.

One hundred and seven pediatric patients (45 males, 62

females) were identified. The age at the operation ranged

from 2 months to 6 years (median age 19.6 ± 8.5 months),

and 45 patients (42.1 %) were younger than 1 year. The

patients’ weight at the time of the operation ranged from 4

to 21 kg (median weight 12.3 ± 6.5 kg), and 51 cases

(47.7 %) were lighter than 10 kg. All patients underwent

preoperative transthoracic echocardiography (TTE) to

determine the mechanism of MR and evaluate the degree of

regurgitation. The etiology of MR included congenital

heart disease in 101 cases and infective endocarditis in six

cases. Eighty-nine MR patients had other associated car-

diac abnormalities, such as a ventricular septal defect, atrial

septal defect, patent ductus arteriosus, pulmonary stenosis,

left ventricular outflow tract obstruction, tetralogy of Fallot

or an anomalous origin of the left coronary artery

(Table 1).

Mitral pathology

MR was graded as none (0), trivial (?), mild (??),

moderate (???) or severe (????) based on the maxi-

mum length and width of the abnormal jet relative to the

left atrium [17, 18]. Echocardiography showed that there

was moderate regurgitation in 38 cases and severe regur-

gitation in 69 cases.

The mitral pathology was classified into three groups

according to the leaflet motion [6, 7]: type I indicated

normal leaflet motion (annular dilatation, leaflet cleft,

leaflet defect), type II was associated with prolapsed leaf-

lets (elongated chordae, elongated papillary muscle, absent

chordae, torn chordae) and type III was associated with

restricted leaflet motion (short chordae, papillary muscle

commissural fusion, papillary muscle hypoplasia)

(Table 2). Annular dilatation was the predominant pathol-

ogy in our series, which was present in 66 cases (61.7 %).

Surgical techniques

Mitral valvuloplasty (MVP) was performed with cardio-

pulmonary bypass under moderate systemic hypothermia.

The techniques used for MVP varied according to the

mitral valve morphology. The methods used for MVP

Table 1 Associated cardiac abnormalities

Associated abnormalities n

Ventricular septal defect 65

Atrial septal defect 13

Patent ductus arteriosus 4

Pulmonary stenosis 3

Left ventricular outflow tract obstruction 2

Tetralogy of fallot 1

Anomalous origin of the left coronary artery 1

Total 89

Table 2 Carpentier classification of mitral valve pathology

Classification of mitral valve pathology n

Normal leaflet motion (type I) 82

Annular dilatation 66

Leaflet cleft 13

Leaflet defect 3

Leaflet prolapse (type II) 22

Elongated chordae 12

Elongated papillary muscle 5

Absent chordae 3

Torn chordae 2

Restricted leaflet motion (type III) 3

Short chordae 1

Papillary muscle commissural fusion 1

Papillary muscle hypoplasia 1

Table 3 Mitral valvuloplasty techniques

Surgical techniques used for MVP n

Annuloplasty 85

Annuloplasty ring 19

Cleft closure 13

Reconstruction of the posterior leaflet 10

Chordal shortening 12

Papillary muscle shortening 5

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included annuloplasty (n = 85), annuloplasty ring (n = 19),

cleft closure (n = 13), reconstruction of the posterior

leaflet (n = 10), chordal shortening (n = 12) and papillary

muscle shortening (n = 5) (Table 3). Annuloplasty,

including REED annuloplasty, posterior annuloplasty and

commissuroplasty, was commonly carried out for annular

dilatation, leaflet cleft, leaflet prolapse and restricted leaflet

motion. An annuloplasty ring was used in children with

significant annular dilatation. A band of pericardium trea-

ted with glutaraldehyde or polytetrafluoroethylene (PTFE)

could be sutured around the posterior annulus and mitral

commissure (Fig. 1). The continuity of the band could be

interrupted once or twice to allow for subsequent growth.

For posterior leaflet prolapse, we preferred to use posterior

leaflet quadrangular or triangular resection, pleating the

posterior annulus, suturing the cutting edge, and some

cases also required a prosthetic ring. Elongation of chordae

or papillary muscle could be used to treat chordal short-

ening or papillary muscle shortening. All patients with

leaflet cleft were repaired by interrupted simple prolene

sutures.

Several techniques were sometimes used in a single

patient. The concomitant cardiac anomalies were treated at

the same time. The results of repair were evaluated by

transesophageal echocardiography (TEE) after cardiopul-

monary bypass.

Follow-up

Follow-up information was obtained from the medical

records and outpatient interviews. All follow-up informa-

tion was recorded on standardized forms and entered

into the computerized database. The echocardiography

examinations were performed by one senior pediatric

cardiologist.

Statistical methods

The statistical analysis was performed with the SPSS ver-

sion 18.0 software program. The freedom from moderate or

severe MR after MVP was determined by the Kaplan–

Meier method. The data were expressed as proportions or

the mean ± SD. Intergroup comparisons were performed

using Student’s t test. Results were considered to be sig-

nificant for values of P \ 0.05.

Results

Perioperative data

MVP was successfully performed in all patients. The mean

cardiopulmonary bypass time was 80.6 ± 32.1 min. The

mean aortic clamp time was 43.2 ± 17.5 min. The results

of intraoperative TEE showed that 106 cases had no to mild

MR, whereas one case had residual moderate MR. This

patient underwent redo repair immediately, and the sub-

sequent regurgitation was trivial.

Early postoperative results

The in-hospital mortality was 0.9 % (1/107). This patient

was a female with a large ventricular septal defect (VSD)

and pulmonary hypertension (PH), who died as a result of a

pulmonary infection at 1 month postoperatively. The early

postoperative complications mainly included low cardiac

output syndrome (n = 3), respiratory dysfunction (n = 3),

pleural effusion (n = 2) and wound infection (n = 1). The

mean postoperative ventilation time was 30.7 ± 28.5 h.

The mean length of the ICU stay was 4.0 ± 3.2 days, and

the mean postoperative hospital stay was 8.6 ± 5.9 days.

Follow-up results

Follow-up data were available for 91 patients (85.8 %)

after hospital discharge. The average follow-up time was

46.5 ± 8.2 months (3–80 months). TTE at 30 days post-

operatively showed that the left atrial dimension (LAd) and

left ventricular end diastolic volume (LVEDV) were sig-

nificantly reduced in the postoperative period compared

with the preoperative values (Table 4). One patient died of

heart failure 10 months postoperatively. Echocardiography

showed that moderate MR was present in five patients, and

one patient had severe MR. The patient with severe MR

underwent reoperation by mitral valve replacement, and

Fig. 1 An annuloplasty ring

Table 4 A comparison of LAd and LVEDV: preoperative vs one

month postoperative

Value Preoperative

(n = 107)

1 month postoperative

(n = 91)

P

LAd (mm) 25.3 ± 7.2 21.5 ± 4.8 \0.05

LVEDV (ml) 55.8 ± 26.3 40.8 ± 23.2 \0.05

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the result was good. The rate of freedom from moderate to

severe regurgitation was 92.3 ± 3.3 % (Figs. 2, 3). There

were no severe complications. None of the patients

developed mitral stenosis during the follow-up period.

Discussion

Pediatric MR is mainly induced by congenital heart dis-

ease, and is frequently associated with other congenital

cardiac abnormalities [15, 16]. The lesions are classified

into three groups according to the leaflet motion: normal,

prolapsed or restricted [5, 6]. MR involves systolic retro-

grade flow from the left ventricle into the left atrium. When

the regurgitant volume is small, patients may not have

symptoms. However, significant MR may increase the

volume of the left ventricle and left atrium, leading to high

pulmonary venous pressure or heart failure, so children

with significant MR, severe symptoms, pulmonary hyper-

tension or other cardiac anomalies should undergo early

surgical treatment [3, 8, 9]. In our cases, the postoperative

left atrial dimension and left ventricular end diastolic

volume were significantly reduced compared with the

preoperative values.

In consideration of the high mortality rate, anticoagu-

lation problems and high reoperation rate because of size

mismatch when performing mitral valve replacement,

mitral valve repair is considered to be the best surgical

treatment in the pediatric population [10, 11, 19]. In our

series, we customized our approach to mitral valve repair

according to the valve lesions, and the following valve

repair techniques were used based on the individual mitral

pathology: annuloplasty (85/107, 79.4 %), annuloplasty

ring (19/107, 17.8 %), cleft closure (13/107, 12.1 %),

reconstruction of the posterior leaflet (10/107, 9.3 %),

chordal shortening (12/107, 11.2 %) and papillary muscle

shortening (5/107, 4.7 %). Several techniques were some-

times used in a single patient. Annuloplasty was performed

in children with annular dilatation, leaflet cleft, leaflet

prolapse or restricted leaflet motion. Children with signif-

icant annular dilatation may need to be treated using an

annuloplasty ring. In our series, annular dilatation (type I)

was in 66 cases (61.7 %), so annuloplasty and an annulo-

plasty ring were used in most patients. We preferred to use

the interrupted prosthetic ring, because the subsequent

growth of the mitral annulus is inevitable in children, so

room for annular growth should be allowed.

The natural history of ventricular septal defect (VSD)

and MR has not been well studied. It is still controversial

whether MR should be treated at the same time as VSD

closure for patients with VSD and MR [18, 20]. If the MR

is significant and is the result of structural mitral valve

abnormalities, mitral valve repair should be considered at

the time of VSD closure. However, it is not clear whether

significant MR should be treated when the mitral valve

morphology is normal. Our experiences suggest that VSD

can cause the left ventricle and mitral annulus to dilate,

which can lead to MR. Therefore, the MR will resolve in

some patients after VSD closure alone, without mitral

valve repair. We concluded that the MR should be treated

if the regurgitation is moderate or severe in patients with

VSD, which might improve the surgical outcome, because

residual MR would affect the patients’ postoperative car-

diac function.

Intraoperative TEE is mandatory for mitral valve repair

[11, 21]. TEE can be used to evaluate the results of repair

and identify the residual MR. If the residual regurgitation is

moderate or severe, redo mitral valve repair or replacement

is necessary [8]. In our series, intraoperative TEE detected

Fig. 2 The freedom from moderate or severe regurgitation after

MVP

Fig. 3 A comparison of mitral regurgitation: preoperative vs. follow-

up

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one patient with residual moderate MR after mitral valve

repair. This case had severe MR with an anterior leaflet

cleft preoperatively. We sutured the anterior leaflet cleft

directly, and the repair result was found to be satisfactory

by injecting saline through the valve orifice into the ven-

tricular cavity. However, intraoperative TEE showed

residual moderate MR, resulting in an immediate redo

repair with posterior annuloplasty, and the subsequent

regurgitation was trivial.

In the present study, MVP could be performed with an

acceptable early or late mortality rate, and a low reoperation

rate has previously been reported in adults [1, 11, 22].

However, MVP remains a surgical challenge in pediatric

patients [5, 6]. The early and mid-term results were encour-

aging at our institute, and these were comparable to or better

than those reported in the literature [15, 16, 23, 24]. This is

partly because of the different patient populations. The pre-

vious papers described both mitral stenosis and MR in their

patients, whereas our patients only had MR. In our cases, the

in-hospital mortality rate was only 0.9 % (1/107). During the

follow-up of our series (range from 3 to 80 months), only one

patient died of heart failure at 10 months postoperatively.

Follow-up echocardiography showed that moderate MR was

present in five patients, and one patient had severe regurgi-

tation. The patient with residual severe regurgitation was a

5-year-old female with severe regurgitation preoperatively,

and an annuloplasty ring was used to constrict the posterior

annulus. Follow-up echocardiography showed severe regur-

gitation 10 months postoperatively, and mitral valve

replacement was performed 1 year after surgery for this

patient. Poor quality of the leaflet and leaflet curl were the

main reasons for the residual severe regurgitation in this

patient. The other five patients with residual moderate

regurgitation were given pharmacological therapy, because

they were too young and their symptoms were alleviated

compared with the preoperative state. The freedom from

moderate or severe mitral regurgitation rate was 92.3 ±

3.3 % at 5 years. Therefore, the early and mid-term results are

satisfactory in our institute.

Conclusion

Pediatric patients with moderate or severe MR need

early surgical treatment. At present, MVP is the objec-

tive in children with significant MR, and the concomi-

tant cardiac anomalies should be treated at the same

time. Individualized treatment based on the specific

pathology is the key to successful surgical therapy for

pediatric MR.

Conflict of interest The authors have no potential conflicts of

interest to declare.

References

1. Cohn LH. Mitral valve repair. Mastery of cardiothoracic surgery.

2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins Inc;

2007. p. 341–52.

2. Rochae Silva A, Herdy GV, Vieira AA, Simoes LC. Surgical

mitral valve repair in children with rheumatic fever. Arq Bras

Cardiol. 2009;92(6):400–4 (417–21, 433–8).

3. Pedrazzini GB, Faletra F, Vassalli G, Demertzis S, Moccetti T.

Mitral regurgitation. Swiss Med Wkly. 2010;140(3–4):36–43.

4. Brizard C. Mitral valve repair in children. Mastery of cardio-

thoracic surgery. 2nd ed. Philadelphia, PA: Lippincott Williams

& Wilkins Inc; 2007. p. 1008–16.

5. Carpentier A, Branchini B, Cour JC, Asfaou E, Villani M,

Deloche A, et al. Congenital malformations of the mitral valve in

children. Pathology and surgical treatment. J Thorac Cardiovasc

Surg. 1976;72:854–66.

6. Chauvaud S, Fuzellier JF, Houel R, Berrebi A, Mihaileanu S,

Carpentier A. Reconstructive surgery in congenital mitral valve

insufficiency (Carpentier’s techniques): long-term results. J Tho-

rac Cardiovasc Surg. 1998;115:84–92 (discussion 92–93).

7. Minich LL, Atz AM, Colan SD, Sleeper LA, Mital S, Jaggers J,

et al. Partial and transitional atrioventricular septal defect out-

comes. Ann Thorac Surg. 2010;89(2):530–6.

8. Wood AE, Healy DG, Nolke L, Duff D, Oslizlok P, Walsh K.

Mitral valve reconstruction in a pediatric population: late clinical

results and predictors of long-term outcome. J Thorac Cardiovasc

Surg. 2005;130(1):66–73.

9. Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes

following surgical mitral valve repair or replacement. Eur J

Cardiothorac Surg. 2007;31:267–75.

10. Beierlein W, Becker V, Yates R, Tsang V, Elliott M, de Leval M,

et al. Long-term follow-up after mitral valve replacement in

childhood: poor event-free survival in the young child. Eur J

Cardiothorac Surg. 2007;31(5):860–5.

11. Tesler UF, Cerin G, Novelli E, Popa A, Diena M. Evolution of

surgical techniques for mitral valve repair. Tex Heart Inst J.

2009;36(5):438–40.

12. Curi–Curi P, Ramırez-Marroquın S, Cervantes-Salazar J, Soule

M, Erdmenger J, Calderon-Colmenero J. Surgical repair of con-

genital mitral valve malformations. Arch Cardiol Mex. 2010;80(2):

87–94.

13. Zias EA, Mavroudis C, Backer CL, Kohr LM, Gotteiner NL,

Rocchini AP. Surgical repair of the congenitally malformed mitral

valve in infants and children. Ann Thorac Surg. 1998;66(5):

1551–9.

14. Oppido G, Davies B, McMullan DM, Cochrane AD, Cheung

MM, d’Udekem Y, et al. Surgical treatment of congenital mitral

valve disease: midterm results of a repair-oriented policy. J Tho-

rac Cardiovasc Surg. 2008;135:1313–21.

15. Stellin G, Padalino MA, Vida VL, Boccuzzo G, Orru E, Biffanti

R, et al. Surgical repair of congenital mitral valve malformations

in infancy and childhood: a single-center 36-year experience.

J Thorac Cardiovasc Surg. 2010;140(6):1238–44.

16. Hetzer R, Delmo Walter EB, Hubler M, Alexi-Meskishvili V,

Weng Y, Nagdyman N, et al. Modified surgical techniques and

long-term outcome of mitral valve reconstruction in 111 children.

Ann Thorac Surg. 2008;86(2):604–13.

17. Sheikh KH, Bengtson JR, Rankin JS, de Bruijn NP, Kisslo J.

Intraoperative transesophageal Doppler color flow imaging used

to guide patient selection and operative treatment of ischemic

mitral regurgitation. Circulation. 1991;84:594–604.

18. Mahadin DR, Srivastava S, Parness IA, Nguyen K, Love BA,

Walsh R, et al. Outcomes of mitral regurgitation associated with

large ventricular septal defect and a normal mitral valve

Surg Today

123

apparatus: does intact atrial septum have an impact? Pediatr

Cardiol. 2011;32(8):1128–31.

19. Gunther T, Mazzitelli D, Schreiber C. Mitral valve replacement

in children under 6 years of age. Eur J Cardio Thorac Surg.

2000;17(4):426–30.

20. Hisatomi K, Isomura T, Sato T, Kosuga K, Ohishi K, Katoh H.

Mitral valve repair for mitral regurgitation with ventricular

septal defect in children. Ann Thorac Surg. 1996;62(6):

1773–7.

21. Berrebi A. Mitral valve repair: echocardiography is its best

friend. Rev Esp Cardiol. 2011;64(7):554–6.

22. Sakaguchi T, Nishi H, Miyagawa S, Yoshikawa Y, Fukushima S,

Yoshioka D, et al. One-knot technique: a simple modification of

the loop technique for mitral valve repair. Surg Today.

2013;43(6):705–7.

23. Aharon AS, Laks H, Drinkwater DC, Chugh R, Gates RN, Grant

PW, et al. Early and late results of mitral valve repair in children.

J Thorac Cardiovasc Surg. 1994;107:1262–71.

24. Delmo Walter EM, Hetzer R. Mitral valve repair in children.

Mitral Valve Repair, II. Darmstadt, Germany: Steinkopff; 2011.

p. 41–56.

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