Yuan et al.

Journal of Cardiothoracic Surgery (2021) 16:63

https://doi.org/10.1186/s13019-021-01443-9

RESEARCH ARTICLE Open Access

Long-term outcomes of mitral valve

replacement in patients weighing less than
10 kg
Haoyong Yuan1,2, Zhongshi Wu1,2, Ting Lu1,2, Yilun Tang1, Jinlan Chen1, Yifeng Yang1 and Can Huang1,2*

Abstract
Background: The outcomes of mitral valve replacement (MVR) in pediatrics especially in the patients weighing less
than 10 kg are not always favorable. This study aimed to measure long-term outcomes of MVR in our institution.
Methods: Nine young children weighing less than 10 kg underwent MVR with mechanical prostheses were
enrolled in this retrospectively study. Kaplan–Meier survival analysis was used for the prediction of freedom from
death and adverse events. Chi-square test was performed to compare outcomes for patients with different ratios of
mechanical prosthesis size and body weight. Fourteen related literatures were also reviewed to support our study.
Results: All patients received bileaflet mechanical prostheses replacement. The surgical technique varied among
the patients with prostheses implanted in the intra-annular (n = 5), supra-annular (n = 1), or with a Dacron conduit
segment in the supra-annular position (n = 3). The valve size/weight ratio ranged from 2.11 to 5.00. There were two
early death and one late death post-operation. The mean follow-up period was 80.67 ± 63.37 months, the
transvalvular gradient was 10.5 ± 1.76 mmHg (range 8 to 12) and the peak gradient of LVOT was 5.00 ± 0.64 mmHg.
One (11.1%) patient underwent an immediate revision MVR after initial MVR due to the periprosthetic leak. No
patients required surgical reintervention or permanent pacemaker placement during long-term follow-up.
Conclusions: The tailored surgical strategy utilized for MVR in infants resulted in reliable valve function and
excellent survival. Although revision is inevitable due to somatic growth, the bileaflet mechanical prostheses
displayed appropriate durability.
Keywords: Mitral valve replacement, Pediatric, Mechanical prosthesis, Lower cardiac output syndrome

Visual abstract Mechanical valve prostheses might be a good choice.

 Key question  Take-home message

What should we do for patients with mitral valve dis- MVR in infants resulted in reliable valve function and
eases weighing less than 10 kg? excellent survival. The mechanical prostheses displayed
appropriate durability.
 Key findings

* Correspondence: huangcan413@csu.edu.cn Introduction

1
Department of Cardiovascular Surgery, The Second Xiangya Hospital of Mitral valve diseases in children are complex and are al-
Central South University, Changsha 410011, Hunan, China
2
Engineering Laboratory of Hunan Province for Cardiovascular Biomaterials, ways accompanied by various cardiac anomalies, making
139# Renmin Road, Changsha, Hunan 410011, P.R. China surgical treatment challenging [1]. Although the
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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
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Yuan et al. Journal of Cardiothoracic Surgery (2021) 16:63 Page 2 of 8

techniques of mitral valve repair (MVP) in children have

been well established and provide acceptable long-term
outcomes, mitral valve replacement (MVR) remains the
sole surgical alternative [2]. Because of early calcification
and short durability of bio-prostheses, mechanical mitral
valve replacement (mMVR) is the most common choice
for the pediatric population, especially for neonates and
infants [3]. In these cases, a larger-sized prosthesis valve
is implanted into the small annulus, possibly causing
high mortality, left ventricular outflow obstruction
(LVOTO), complete atrioventricular block postopera-
tively, pulmonary vein stenosis, low valve durability and
need for anticoagulant management postoperatively [4].
During the past decades, many techniques and pros-
thesis have been employed to treat mitral valve diseases Fig. 1 Valves implanted supra-annularly with a tilt
in infants and the outcomes of the MVR in patients
weighing less than 10 kg are not always favourable. To
better understand the optimal approach to this complex Three patients underwent MVR concomitant with the
problem, we retrospectively examined our experience repair of the associated cardiac abnormalities, including
with children less than 3 years old and weighing less ventricular septal defect (VSD) closure (n = 1), ligation
than 10 kg who underwent mMVR. of patent ductus arteriosus (PDA) (n = 1), correction of
coarctation of the aorta (n = 1). Intraoperative trans-
Patients and methods esophageal echocardiography was used to confirm ad-
Patients equate prosthetic valve function in all cases.
We considered all patients weighing 10 kg or less and
younger than 3 years old who underwent MVR with Follow-up
mechanical prostheses at the Second Xiangya Hospital Postoperatively, anticoagulation was obtained using so-
of Central South University in China between November dium warfarin, aiming at an international normalized ra-
2006 and April 2019. Data were acquired from hospital tio (INR) of 2.0–2.5. Temporary anticoagulation with
records and the institute’s cardiac database and were an- intravenous heparin was also used during the 24 h after
alyzed retrospectively. This study was approved by the the surgery and invasive procedures, aiming at an acti-
Institutional Ethics Committee and written informed vated partial thromboplastin time (APTT) of 1.5–2.0
consent was obtained from parents or guardians before times above baseline.
surgery to allow the use of their data.
Statistical analysis
Surgical technique The Statistical Package for Social Sciences (SPSS) ver-
All patients underwent median sternotomy and standard sion 22.0 (IBM) was used for all data analyses. Descrip-
cardiopulmonary bypass under moderate hypothermia tive statistical analysis was undertaken using continuous
(range 28 to 32 °C). The mitral valve was exposed data presented as median and interquartile range (IQR)
through an “L” shaped atrial septectomy (from the en- or mean ± standard deviation and categorical variables as
trance of superior vena cava to the front of the coronary raw data and/or percentages. Kaplan–Meier survival
sinus). mMVR was performed after unsuccessful mitral analysis was used for the prediction of freedom from
valvuloplasty or when the valve was judged to be unsuit- death and adverse events. Chi-square test was performed
able for repair. The posterior leaflet tissue and subvalvu- to compare outcomes for patients based on the ratio of
lar apparatus of the mitral valve were preserved mechanical prosthesis and weight.
wherever possible. In patients with infective endocardi-
tis, all valve tissue was excised and sent for bacterial cul- Result
tures. Valves were implanted in either a supra- or intra- Demographics
annular position; supra-annular valves were sometimes A total of nine pediatric patients were included in this
tilted either anteriorly or posteriorly to optimize posi- study; there were three boys and six girls in this cohort.
tioning. When doing the skirt super-annular MVR, a The ages of seven patients were less than 1 year at the
segment of Dacron conduit was interruptedly sutured in initial mMVR procedure. The mean age at the initial
the annular position and then the mechanical prosthesis mMVR was 11.88 ± 11.29 months (range 1 months to 32
was running sutured to the conduit (Fig. 1 and Video). months) and the mean body weight was 6.83 ± 2.56 kg
Yuan et al. Journal of Cardiothoracic Surgery (2021) 16:63 Page 3 of 8

(range 4.0 to 9.5 kg). Two patients weighing less than 5 intra-annular or supra-annular MVR. One died from
kg were diagnosed with severe congenital mitral valve hematencephalon which was secondary to fungal endo-
regurgitation and stenosis and were treated with ventila- carditis and the other two died from low cardiac output
tor before the operation. Three patients were diagnosed syndrome (Fig. 3). One underwent redo MVR during
with severe mitral valve regurgitation with coarctation hospital stay because of a perivalvular leak. The postop-
(CoA), patent ductus arteriosus, or ventricular septal de- erative intensive care unit (ICU) stay ranged from 1.8 to
fect (Table 1). Four (44.4%) patients underwent previous 89 days with a median of 8 days. The median duration of
surgical procedures, of which three underwent partial or postoperative ventilation was 120 h ranged from 19 to
complete AVSD repair and one underwent VSD closure 504 h (Table 3). After a mean follow-up of 80.67 ± 63.37
and MVP, one of which was accompanied by fungal months, the transvalvular gradient was 10.5 ± 1.76
endocarditis after the partial AVSD repair. mmHg (range 8 to 12) and the peak gradient of LVOT
was 5.00 ± 0.64 mmHg. No patients required surgical
Surgical technique reintervention for the development of left ventricular
All patients received bileaflet mechanical prosthetic outflow tract obstruction or permanent pacemaker
valves (ATS Medtronic, Minneapolis, Minnesota), with placement during long-term follow-up (Table 4).
three receiving mitral prostheses and six receiving
inverted aortic prostheses. Surgical technique varied be- Discussion
tween patients with valves implanted intra-annularly MVP is considered to be the current standard treatment
(n = 5), supra-annularly (n = 1), or supra-annularly with a for children with mitral valve abnormalities. Unfortu-
segment of Dacron conduit (n = 3). The valve size/weight nately, there are certain pediatric patients who will need
ratio ranged from 2.11 to 5.00 (average 3.28 ± 0.91) and an MVR instead of an unsuccessful MVP; difficulties for
there is significant difference between the ratio over 3 both decision-making and treatment options may arise
and below (p = 0.03) for early mortality (Fig. 2 and [5]. The most common indications for MVR in children
Table 2). The cardiopulmonary bypass time was include rheumatic disease, endocarditis, mitral stenosis
154.33 ± 68.25 min (range 57 min to 285 min), and the in Shone’s syndrome or failed atrioventricular septal de-
aorta clamp time was 103.89 ± 47.94 min (range 33 min fect (AVSD) repair. In our studies, over 50% of the pa-
to 173 min). At our institution, patient INRs were strictly tients were diagnosed with mitral valve disease with
monitored at outpatient hematology clinics during infective endocarditis or failed AVSD repair. Bioprosth-
follow-up; there were no emergency operations for acute eses were not the appropriate choices for MVR in chil-
valve thrombosis or a significant event in other series. dren and infants due to the lack of durability and
unavailability of small-sized prostheses. The pulmonary
Early and long-term follow-up outcomes autografts and Contegra conduits were employed to
There were two early death within 1 month and one late treat pediatric patients with small annular to avoid long-
death post-operation, all the three dead cases received term anticoagulation. However, because of accelerated

Table 1 Patients list

NO. Sex Age Weight Diagnosis Procedure VALVE Ratio Redo Clamping Bypass Ventilation ICU PG 1 week Death
(SIZE) time Stay post
1 F 9 9 MR, Post CAVSD SSMVR 19 2.11 N 173 285 66 3.3 8 N
Repair
2 M 3 5.5 MR, VSD SMVR 19 3.45 Y 125 185 336 14 Y
3 F 3 4.7 MS, MR SSMVR 19 4.0 N 104 121 124 10 12 N
4 F 1 3.8 Post MVP, MR MVR 19 5 N 160 209 48 2 Y
5 F 12 7 IE, MR, Post PAVS MVR 21 3 N 56 95 504 89 Y
D Repair
6 F 21 9 MR, PDA MVR 25 2.7 N 33 57 19 1.8 12 N
7 M 2 4 MS, MR SSMVR 16 4 N 124 171 384 20 12 N
8 F 32 9.5 MR, Post PAVSD MVR 25 2.6 N 104 155 72 7 10 N
Repair
9 M 24 9 MR, CoA MVR 25 2.7 N 56 111 120 8 9 N
Age (months), Clamping and Bypass (minute), Ventilation time (hour), ICU Stay (day), Weight (kg), Size (mm), PG (mmHg), F Female, M Male, N NO, Y Yes, Ratio
Valve size/weight, Redo Reintervention after initial MVR, MR Mitral valve regurgition, MS Mitral valve stenosis, VSD Ventricular septal defect, PDA Patent duct
arteriol, IE Infective endocardiatis, PAVSD Partial artroventricular septal defect, CAVSD Complete artroventricular septal defect, CoA Coarctation, MVP Mitral valve
repairment, MVR Mitral valve replacement, SMVR Supra-annul mitral valve replacement, SSMVR Skirt supra-annul mitral valve replacement, PG Pressure gradient
Yuan et al. Journal of Cardiothoracic Surgery (2021) 16:63 Page 4 of 8

Fig. 2 The patients Ratio between valve size/body weight

degeneration and calcification, these techniques require low cardiac output syndrome. The last two patients re-
long-term follow-up [6, 7]. Similar to the Ross proced- ceived relatively large prosthesis, and the size/body
ure, the Ross II procedure makes one-valve problem to weight ratio was 3.45 and 5, respectively, which accord
two-valve problems, possibly resulting in early regurgita- closely with the results reported by Caldarone et al. [1].
tion due to the lack of valve commissural support and Although there were a relatively small number of cases
higher trans-valvar pressure gradiant. Considering the in our study, we found that smaller annulus, heart failure
better durability, availability, and hemodynamic per- before the procedure and fungal infections were risk fac-
formance, mechanical valves are the preferred mitral tors for short-term mortality. Previous studies demon-
valve substitute in children. strated that age less than 2 years old at MVR was a risk
Historically, MVR in infants has been associated with factor for operative mortality [20]. Rafii et al. found that
significant morbidity and mortality and long-term sur- there was no significant difference in survival between
vival is lower than that of infant MV repair [8]. Conse- patients aged less than 2 years and patients aged 2 to 18
quently, surgical techniques and strategies have evolved years, and age less than 2 years remained a risk factor
to optimize outcomes. The reported operative mortality for reoperation but not for mortality [13]. Bileaflet
for MVR in infants is 5 to 30% and the 10- and 30-year mechanical prostheses from ATS Medtronic (Minneap-
survival for these patients was recently reported up to olis, Minnesota) were implanted in nine patients in our
75% [5] (Table 5). Heart block requiring pacemaker im- study. Because the smallest size of the available mechan-
plantation, endocarditis, thrombosis, stroke, an increased ical mitral valve in our institute is 25 mm, six patients
ratio of prosthetic size/weight and supra-annular pos- were implanted with mechanical aortic valve prostheses.
ition were all found to be statistically significant predic- Due to the low profile, excellent hemodynamics and
tors of early mortality [9]. In our institute, there were good durability, a bileaflet mechanical valve is the pros-
two early death within 1 month and one late death. thesis of choice in the mitral position in children [18].
Among the three dead cases, one died from hematence- Size mismatch between the mechanical prosthesis and
phalon secondary to fungal infection and two died from mitral valve annulus is considered to be a risk factor for
operative mortality [21]. Caldarone et al. showed that 1-
year survival rate was 91% when the prosthesis size–to–
Table 2 Comparison of the survival between ratio ≥ 3 and patient body weight ratio was < 2; however, the survival
below rate was only 61% when the ratio > 4 and only 37% when
Death Survival P value the ratio < 5 [1]. In our study, the ratio ranged from 2.1
Ratio ≥ 3 3 2 P = 0.03
to 5 and the ratios of the deceased patients were all over
3. This suggests that an appropriate mechanical pros-
Ratio < 3 0 4
thesis is essential for successful MVR in children.
Yuan et al. Journal of Cardiothoracic Surgery (2021) 16:63 Page 5 of 8

Fig. 3 Kaplan-Meier analysis of survival

Prosthesis size should be carefully chosen based on the risk factor for early mortality because of the reduction of
body weight, age, and mitral valve annular size of an in- LA volume and compliance and aneurysm formation in
dividual patient. the segment of LA between the prosthesis and the annu-
Multiple surgical techniques were employed in the lus [2]. One of our patients had valves implanted with a
MVR. The appropriate mechanical valve was implanted tilt, similar to that described by Moon and colleagues
in the annulus if the size matched. Because of the link [10], which involved suturing part of the valve onto the
between the mechanical valve size and freedom from native annulus and the remainder to the left atrial wall
redo MVR, a large mechanical prosthesis was implanted or atrial septum. The prosthesis was thereby implanted
to the smaller annulus, possibly causing atrioventricular supra-annularly with a tilt either anteriorly or posteriorly
block and left ventricle outflow tract obstruction related to prevent impingement on the LVOT, pulmonary vein
to valve impingement on surrounding cardiac structures orifices, and conduction tissue. Two weeks later, the pa-
[22]. In the neonate or infant with a small native annu- tient underwent redo MVR because of the periprosthetic
lus, implantation of commercially available prosthetic leakage and died from acute low cardiac output syn-
valves in the annular position can be problematic. Pla- drome. We suggest that implanting the prothesis supra-
cing the prosthesis in a supra-annular position is an al- annularly with a tilt may have caused the periprosthetic
ternative when a more traditional annular implantation leakage and the immediate redo MVR. Three patients
is not possible. The prosthetic valve was implanted with had Dacron Hemashield (Meadox Medicals, Inc., Oak-
interrupted pledget polyester sutures with the pledgets land, NJ) with interrupted sutures sewn to the native
on the atrial side of the prosthesis [10]. Previous publica- valve annulus, after which the prosthetic valve was sewn
tions suggested that the early results with supra-annular with running sutures into the conduit, among which two
MVR in children were discouraging and identified it as a had a size/body weight ratio over 4. We employed the
Dacron conduit that would be softer and provide better
Table 3 Patients character list hemodynamics than the Gore-Tex conduit. The pros-
Age at operation 11.88 ± 11.29 months thetic valves were implanted to the conduit follow sutur-
(range 1 months to 32 months)
ing the conduit wall to the annulus, which may provide
Weight at operation 6.83 ± 2.56 kg (range 4.0 to 9.5 kg) convenience for the surgeon to implant a larger valve in
Interval from original ration 80.67 ± 63.37 months a smaller space, also reducing the occurrence of peri-
The cardiopulmonary bypass time 154.33 ± 68.25 min prosthetic leakage [23]. The avoidance of directly sutur-
(range 57 min to 285 min) ing on mitral valve annulus or left atrial wall may
The aorta clamp time 103.89 ± 47.94 min contribute to eliminating excessive traction of the left
(range 33 min to 173 min) atrial tissue, left circumflex coronary artery, and pul-
Duration of ventilation Median 120 h monary vein orifices. This surgical technique might be
(ranged from 19 to 504 h)
more tolerant to large prosthesis size according to our
Duration of ICU stay Median 8 days experience. The technique of intermittent suture would
(ranged from 1.8 to 89 days)
preserve the growth potential and may provide the
Yuan et al. Journal of Cardiothoracic Surgery (2021) 16:63 Page 6 of 8

Table 4 Follow up for the latest echocardiograft examination buffering and grasping the height of the Dacron conduit
Patients Follow Up PG (LVOT) PG (MV) mPAP that can effectively avoid this complication.
1 8 5 8 20 Redo valve replacement is inevitable following infant
3 32 5 11 16
MVR because of somatic growth. The duration has been
reported to be 8.6 ± 6.6 years in children < 5 years of age
6 108 6 12 20
at initial MVR and 7.3 years following infant MVR [24].
7 36 5 12 18 The most common reported indication for early redo
8 144 5 11 17 valve replacement is excessive pannus formation, par-
9 156 4 10 16 ticularly in infants and young children. Valve type, size,
Follow up (months), MV Mitral valve, PG Pressure gradient, LVOT left and positioning were thought to optimize the longevity
ventricular outflow tract, mPAP Mean pulmonary artery pressure of the implanted prosthesis and maximize time until
redo MVR [11]. As presented in our follow-up results,
the transvalvular gradients of the implanted mechanical
possibility for the replacement of a larger mitral valve in aortic valve and mitral valve demonstrated no significant
the future. The mitral valve on the annulus will inevit- differences. Studies indicated that choosing a mechanical
ably lead to the reduction of the left atrium content, valve larger than 19 mm could considerably delay the
possibly leading to pulmonary vein obstruction or even redo MVR [5], due to valve size ≥19 mm. There were no
pulmonary hypertension. However, in our case, we did redo MVRs for somatic growth in our cohort.
not find the existence of pulmonary vein stenosis or pul- There are several limitations to this study. First, it was
monary hypertension. In fact, either mitral regugitation a single-centre study, and therefore may be subject to se-
or mitral stenosis patients has a dilated left atrium. We lection bias. For this reason, we instituted strict inclu-
believe that the larger left atrium has sufficient space for sion and exclusion criteria. Multi-centre studies are

Table 5 Literature review of long-term survival and freedom from redo MVR after MVR
Studies Cases Age Follow up Survival Free from Redo MVR
rate
Mater, Kathryn. 2019. Australia 22 Mean age 6.8 ± 4.1 6.2 ± 4.4 years 100% 86.1% at 1 years, 80.7% at 5 years and 21.2% at 10 years
[9] months
Raffaele Giordano. 2015. Italy 7 Mean age 13.3 ± 11.2 67.1 ± 34.8 100% 71.4%
[2] months months
Christopher A. Caldarone 139 Mean age 1.9 ± 1.4 Median 6.2 74%
.2015. USA [1] years years
Jiyong Moon. 2015.J apan 18 Mean age 4.0 ± 1.8 4.5 ± 3.8 years 89.1% 57.8% at 10 years
[10] months
John W. Brown. 2012. USA 97 Median age 8 years 12.8 ± 10.1 71% 94% at 1 year, 82% at 5 years, 71% at 10 years, and 63%
[11] years at 20 and at 35 years
Hyung-Tae Sim. 2012. Korea 19 Mean age 7.6 ± 5.5 76 ± 56 100% 94.7 ± 5% at 10 years
[12] years months
Daniela Y. Rafifii. 2011. USA 18 Median age 1.2 years Median 5.4 82% 69% at 5 years and 40% at 10 years
[13] years
Kirk R. Kanter. 2011. USA [14] 15 Mean age 337 ± 412 4.3 ± 2.8 84% 69% at 5 years and 21% at 10 years
days years,
Bahaaldin Alsoufi. 2009. 79 Median age 24 4.1 ± 3.7 years 62%
Canada [15] months
ElifSeda Selamet Tierney. 118 Median age 16.3 Over 30 years 56% 72% at 5 years and 45% at 10 years
2008. USA [8] months
J. S. Sachweh. 2007. Germany 17 Mean age 4.3 ± 4.3 9.1 ± 6.6 years 94.1% 93.4% at 1 year 89.0% at 5 and 10 years
[16] years
Wolfram Beierlein. 2007. UK 54 Median age 3.0 years Median 9.2 33% 45.3% at 5 years and 17.3% at 10 years
[17] years
Hunaid A. Vohra. 2007. UK 24 Mean age 1.4 ± 1.3 Median 7.5 75.7%
[18] years years
Naoki Wada. 2005. Japan [19] 18 Mean age 1.02 ± 0.72 3.3 ± 3.5 years 68.9% 87.1% at 5 years and 69.6% at 10-years
years
Yuan et al. Journal of Cardiothoracic Surgery (2021) 16:63 Page 7 of 8

needed to validate our findings. Bedsides that, study is Competing interests

limited by its retrospective design and the relatively There’s no completing interests for this study.

small patient population. Received: 6 December 2020 Accepted: 17 March 2021

Conclusion
In terms of long-term outcomes, MVR is a good alterna- References
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